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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601035
Report Date: 08/03/2022
Date Signed: 08/04/2022 08:25:16 AM

Document Has Been Signed on 08/04/2022 08:25 AM - 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:CARRIAGE CAREFACILITY NUMBER:
075601035
ADMINISTRATOR:TUAZON, GABRIEL & ERLINDAFACILITY TYPE:
740
ADDRESS:1959 CARRIAGE DRIVETELEPHONE:
(925) 977-9678
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 5DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:ERLINDA TUAZONTIME COMPLETED:
07:00 PM
NARRATIVE
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On 08/3/22 at 3:00 PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon entry into facility, LPA explained the purpose of the visit. LPA met with and toured the facility with Licensee ERLINDA TUAZON.

Facility has a Covid-19 Mitigation Plan and an Infection Control Plan. However, they are not following many aspects of the Covid-19 Mitigation Plan, including a lack of indoor signage regarding Covid-19 mitigation. The designated infection control leader is the Licensee. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log and a no touch thermometer, hand sanitizer, and face masks. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants.

Carbon monoxide and smoke detectors were fully functional and the fire extinguisher had been serviced within one (1) year and it was fully charged. However, no Emergency/Disaster plan was posted. Centrally stored medications were in locked cabinets, and sharp objects were stored in locked closets and cabinets. The temperature inside of the facility was 78 and the hot water was 110 degrees Fahrenheit, both of which were in the safe range. An administrator is on site more than the required 20 hour minimum each week to oversee business operations.

Facility cited with 3 Type B deficiencies:

Continues on LIC 809-C . . .
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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 4
Document Has Been Signed on 08/04/2022 08:25 AM - It Cannot Be Edited


Created By: James Sampair On 08/03/2022 at 05:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CARRIAGE CARE
FACILITY NUMBER: 075601035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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 because few signs were posted in the facility to mitigate Covid-19. Facility does not have a 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles) and a list including items on hand or indicating where such items will be acquired (such as CCL Regional Office) and when which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Licensee shall: (1) post 6 additional signs in the facility to promote cough and sneeze etiquette and physical distancing AND 1 handwashing instruction poster in EVERY bathroom and (2) review donning and doffing PPE videos from CDC with all of the licensee's staff members and (3) review Infection and Control Plan and (4) purchase 30-day supply of PPE (minimum of 80 facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles).
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(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 in all of the residents by not completing the MAR for the past 3 days, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Licensee will complete all of the MAR records and attest to that fact to the LPA on or before the POC due 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 Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2022 08:25 AM - It Cannot Be Edited


Created By: James Sampair On 08/03/2022 at 05:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CARRIAGE CARE
FACILITY NUMBER: 075601035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Licensee shall send fully completed 610E form to LPA on or before POC due 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 Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


LIC809 (FAS) - (06/04)
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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: CARRIAGE CARE
FACILITY NUMBER: 075601035
VISIT DATE: 08/03/2022
NARRATIVE
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. . . Continued from LIC 809
  • Infection Control Practices - Type B: 87468.1(a)(2) - Few signs were posted in the facility to promote handwashing, cough/sneeze etiquette, and physical distancing. Additionally, the facility does not have a 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles) nor a list including items on hand or indicating where such items will be acquired (such as CCL Regional Office) and when.
  • Incidental Medical and Dental - Type B: 87465(c)(3) - MAR records incomplete.
  • Disaster Preparedness - Type B: 1569.695(a) - Emergency and Disaster Plan 610E was incomplete and an incomplete resident roster.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 08/10/22:
  • · LIC500 - Personnel Report
  • · LIC308 - Designation of Facility Responsibility
  • · LIC610E - Emergency/Disaster Plan
  • · Evidence of Liability Insurance & Surety Bond

A total of 3 deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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