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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601253
Report Date: 08/09/2022
Date Signed: 08/09/2022 02:43:38 PM

Document Has Been Signed on 08/09/2022 02:43 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:LIFETIME CARE 2FACILITY NUMBER:
075601253
ADMINISTRATOR:RUSSELL, ELLEN M.FACILITY TYPE:
740
ADDRESS:1720 MEDITERRANEO PLACETELEPHONE:
(925) 260-8700
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 4DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ellen Russell, Administrator TIME COMPLETED:
03:10 PM
NARRATIVE
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On 8/9/2022 at 01:20 PM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an infection control annual required inspection. LPA met with S2, LPA called Administrator Ellen Russell and informed her the purpose of the visit. Facility has census of 4.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. No bodies of water. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to residents and refilled every at least 30 days.

Facility has enough 2-day perishable food and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE (mask). Facility has a mitigation plan and infection control plan. Facility maintains record of routine screening for residents and staff.

LPA observed the following:



· At 1:31pm LPA observed over the counter medications are accessible to residents in care. Corrected during the visit, staff locked medication.
· LPA requested a copy of an updated Covid19 training for all staff. Staff last Covid19 training was 2021. (Technical assistance provided)

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Ellen Rusell. Exit interview conducted and appeal rights copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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 08/09/2022 02:43 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/09/2022 at 02:27 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: LIFETIME CARE 2
FACILITY NUMBER: 075601253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 in staff nutritional supplement or vitamins was accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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Cleared and corrected. Staff locked nutritional supplement or vitamins during the visit.
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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022


LIC809 (FAS) - (06/04)
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