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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201146
Report Date: 09/26/2022
Date Signed: 09/26/2022 12:10:44 PM


Document Has Been Signed on 09/26/2022 12:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ANASTASIAFACILITY NUMBER:
019201146
ADMINISTRATOR:MAHLER, OCTAVIANFACILITY TYPE:
740
ADDRESS:3646 EAST AVENUETELEPHONE:
(510) 692-7785
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 2DATE:
09/26/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Octavian Mahler, AdministratorTIME COMPLETED:
12:25 PM
NARRATIVE
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On 9/26/2022 at 8:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conducted a post licensing inspection. LPA met with caregiver, Remus Hanganu. Administrator, Octavian Mahler arrived 10 minutes later.

Upon entry, staff did not conduct COVID-19 screening for LPA. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area, and backyard. Facility has a 2-day supply of perishable and 7-day non-perishable food supplies. Hot water temperature was measured at 113.5 degrees F in the kitchen sink. Grab bars and non-skid materials were observed in the residents’ bathrooms. Extra linens and towels were observed in the hallway closet. Carbon monoxide and smoke detector were observed. There are no bodies of water observed. Medications were centrally stored and lock in a cabinet. Fire extinguisher was observed to be full.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food supplies, and paper supplies are sufficient. LPA verified facility had liability insurance.

At 9:20AM, LPA observed unlocked cleaning supplies in the hallway bathroom and kitchen cabinet. Staff locked up cleaning supplies during inspection.

At 10:00AM, LPA observed S1 did not have health screening during record review.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


Document Has Been Signed on 09/26/2022 12:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANASTASIA
FACILITY NUMBER: 019201146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies in the bathroom and kitchen which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/27/2022
Plan of Correction
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Staff locked up the cleaning supplies during inspection.

Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 09/26/2022 12:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ANASTASIA
FACILITY NUMBER: 019201146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having health screening for S1 which poses a potential health and safety risk to persons in care.
POC Due Date: 10/17/2022
Plan of Correction
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Administrator has agreed to obtain health screening for S1 and submit a copy to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022
LIC809 (FAS) - (06/04)
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