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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201146
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:26:36 PM


Document Has Been Signed on 06/19/2024 03:26 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: 5DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Octavian Mahler, AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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On 6/19/2024 at 8:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Octavian Mahler and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory residents, of which 6 residents may be bedridden, and 6 residents may be under hospice care.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and purchased on 6/19/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 113.2 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. The facility has a written emergency disaster plan. Last disaster drill was conducted on 5/29/2024.

LPA reviewed 5 resident and 4 staff files starting at 10:00AM. LPA interviewed 2 residents and 2 staff. LPA reviewed a sample of resident's medications starting at 12:30PM.

At 9:15AM, LPA observed unlocked medication in the refrigerator. Staff locked up the medication in a lockable refrigerator during inspection. LPA also observed unlocked medications in R3's room and staff locked up the medications.

At 11:00AM, LPA observed S4's file was incomplete.

At 1:00PM, LPA observed facility does not have MAR (Medication Administration Records) for resident's PRN medications.
(Continue on LIC809C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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


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
VISIT DATE: 06/19/2024
NARRATIVE
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At 1:15PM, LPA observed doctor's order dated 6/8/2024 states that R3 has PRN orders for Chlorhexidine Gluconate and Guaifenesin. However, facility does not have the medications available for R3.

At 1:30PM, LPA observed facility does not have hospice training records when R1 was admitted to hospice care.

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: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/19/2024 03:26 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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(f)(1)
Hospice Care for Terminally Ill Residents
(1) The record of each training session shall specify the names and credentials of the trainer, the persons in attendance, the subject matter covered, and the date and duration of the training session.

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 hospice training records available which poses a potential health and safety risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Administrator has agreed to obtain training from hospice agency and submit training documents to CCLD by POC date.
Type B
Section Cited
CCR
87412(g)
(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

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 S4's file completed which poses a potential health and safety risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Administrator has agreed to complete all forms necessary for S4's file and submit a written statement 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: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 06/19/2024 03:26 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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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 medications in the refrigerator and R3's room which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Staff locked up the medications during inspection.

Deficiency cleared.
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
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 not having PRN medications available which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Administrator has agreed to obtain medications for R3 (Chlorhexidine Gluconate and Guaifenesin) and submit pictures 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: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 06/19/2024 03:26 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: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
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 MAR for PRN medications which poses a potential health and safety risk to persons in care.
POC Due Date: 07/15/2024
Plan of Correction
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Administrator has agreed to obtain MARs for all PRN medications for all residents. Administrator will submit written statement of completion to CCLD by POC date.
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: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6