075601221-12-3-2024-15-AS-LAWN-DBM4SR-20241203182159

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601221
Report Date: 12/03/2024
Date Signed: 12/03/2024 06:22:16 PM

Document Has Been Signed on 12/03/2024 06:22 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	LARKEY PARK HOME CARE		FACILITY NUMBER:	075601221
ADMINISTRATOR/ DIRECTOR:	CAMACLANG, ALBERTINA R		FACILITY TYPE:	740
ADDRESS:	2532 LARKEY LANE		TELEPHONE:	(925) 287-8590
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Jenny Laguna, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	06:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/03/2024 at 12:45 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Jenny Laguna and explained the purpose of the visit. Jenny phoned Administrator, Albertina Camaclang, to inform of visit. The facility’s fire clearance was approved for capacity of six (6) residents. In which all six (6) can be non-ambulatory. Hospice waiver approved for one (1). Administrator's Certificate # 7002848740 expires 02/16/2026. LPA toured facility with Jenny including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of six (6) total bedrooms which six (6) bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 02/01/2024. Emergency Disaster Plan was last posted on 11/01/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 09/12/2024. LIC809-C Continued...

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/03/2024 06:22 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LARKEY PARK HOME CARE	FACILITY NUMBER: 075601221
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having health screening and TB (LIC 503) for S5 and S6 which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Administrator agrees to submit a copy of health screening and negative TB for S5 and S6 to CCLD by 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LARKEY PARK HOME CARE	FACILITY NUMBER: 075601221
	VISIT DATE: 12/03/2024

NARRATIVE

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LIC809-C (Page 2)

LPA reviewed five (5) residents records. LPA reviewed six (6) staff records and four (4) of six (6) have current first aid training and associated to the facility.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

THE FOLLOWING WERE OBSERVED DURING VISIT:

At 2:40 PM LPA observed two (2) Razor Scooters laying on side of house.
At 2:45 PM LPA observed boxes, microwave, glass window pane located outside backyard.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/10/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan - Reviewed
Liability Insurance - Reviewed
Current Administrator’s Certificate - Reviewed

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/03/2024 06:22 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LARKEY PARK HOME CARE	FACILITY NUMBER: 075601221
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by having an approved hospice waiver for increased capacity resident R2 who was admitted with hospice services which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit a self-certification of reading and understanding the regulation moving forward and submit a hospice waiver request for approval for R2 to CCLD by POC due date.

Section Cited

87632 Hospice Care Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not sending notification of hospice services initiated for R1 and R2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Administrator agreed to self-certify that they read and understand the regulation moving forward and submit notification of hospice services for R1 and R2 to CCLD by 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/03/2024 06:22 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LARKEY PARK HOME CARE	FACILITY NUMBER: 075601221
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC 1569.618(c)(3) (c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having current First Aid and CPR for S5 and S6 which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit updated First Aid and CPR certificates for S5 and S6 to CCLD by POC due date.

Section Cited

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by having two Razor scooters, boxes, microwave and glass window pane removed from outside backyards and cleaned up which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove items and clean back yards and submit a photo to CCLD by 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/03/2024 06:22 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LARKEY PARK HOME CARE	FACILITY NUMBER: 075601221
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having the report for R1, R2, R3, and R5's use of oxygen reported to local fire department and in their files which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Administrator agreed to read the regulation, self certify and send self-certification to CCLD by POC due date. In addition, submit copies of letters sent to local fire dept informing that oxygen in use for R1, R3 and R5.

Section Cited

87705 Care of Persons with Dementia (c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having updated Physician's Report for R5 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit an updated Physician's Report (LIC602A) for R5 to CCLD by 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/03/2024 06:22 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LARKEY PARK HOME CARE	FACILITY NUMBER: 075601221
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87458 Medical Assessment (c) The licensee shall obtain an updated medical assessment when required by the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by having updated Physician's Reports for R3 and R4, the last LIC 602A were from year 2022 which poses a potential health, and safety risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit updated Physician's Reports for R3 and R4 to CCLD by POC due date.

Section Cited

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having an updated Appraisal Needs and Services for R3 and R4 which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Administrator agreed to conduct updated Appraisals for R3 and R4 and submit to CCLD by 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.

Bennett Fong	TELEPHONE: (510) 725-7919
Lori Alexander-Washington	TELEPHONE: (510) 285-3934
	DATE: 12/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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