075601290-6-11-2021-15-AS-DPAO-C3VVXY-20210611165020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601290
Report Date: 06/11/2021
Date Signed: 06/11/2021 04:50:49 PM

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:	LA ORINDA CARE HOME		FACILITY NUMBER:	075601290
ADMINISTRATOR:	WONG, RONALD G.		FACILITY TYPE:	740
ADDRESS:	2180 LA ORINDA PLACE		TELEPHONE:	(925) 798-3570
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	6	CENSUS: 6	DATE:	06/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Editha Namoro, Staff		TIME COMPLETED:	05:13 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 06/11/21 at 2PM, Licensing Program Analyst (LPA) conducted an infection control annual inspection and explained the purpose of the visit with S1 and S2. LPA observed Administrator was not available during visit. LPA observed one central entry point designated for universal entry screening at the main entrance. LPA observed visitors' log did not have a column for temperature logs for residents, staff and visitors. LPA observed no touch temperature probe was missing at the screening station. S1 showed LPA a no touch temperature probe that is not working. S1 stated it does not have a battery. One of the residents told LPA that staff has not checked their temperature for over 2 months. LPA observed S1 and S2 were not wearing face masks during visit. LPA advised staff to wear a face mask at all times while working at the facility. Facility has a completed mitigation plan in place dated 01/21/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with staff as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed 2 fire extinguishers fully charged but was last inspected on 02/14/2020. LPA advised staff to have both fire extinguishers re-inspected as soon as possible or have them replaced with new ones. Per staff, the designated infection control leader is the administrator. Continued on next page, LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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

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: LA ORINDA CARE HOME	FACILITY NUMBER: 075601290
	VISIT DATE: 06/11/2021

NARRATIVE

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All staff and residents have been fully vaccinated since February 2021.There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 73 degrees Fahrenheit. Smoke and Carbon monoxide detectors were operational. A written Emergency/Disaster plan dated 11/01/2020 was displayed in the kitchen area. Centrally stored medications were locked in kitchen cabinets. Toxic chemicals were locked in the garage.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: LA ORINDA CARE HOME	FACILITY NUMBER: 075601290
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation, staff was not wearing face masks during LPA visit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2021
	Plan of Correction
1 2 3 4	Staff corrected deficiency during visit. Both S1 & S2 wore face masks upon reminder by LPA and understood that they need to wear face masks at all times while working at the facility.

Type A

Section Cited

CCR

87411(d)(5)

Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff was not understanding of cohorting residents if necessary to mitigate infection which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2021
	Plan of Correction
1 2 3 4	Staff corrected deficiency during visit. Staff agreed to cohort residents if necessary when there is a COVID-19 infection.

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: LA ORINDA CARE HOME	FACILITY NUMBER: 075601290
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

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, facility does not have a designated isolation room for quarantining residents if necessary which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2021
	Plan of Correction
1 2 3 4	Staff corrected deficiency during visit. Staff agreed to designate an isolation for potential COVID-19 infected resident.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

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