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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601371
Report Date: 06/11/2021
Date Signed: 06/11/2021 01:16:15 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:LAFAYETTE CARE HOME IIFACILITY NUMBER:
075601371
ADMINISTRATOR:LI KURIHARA, LINDAFACILITY TYPE:
740
ADDRESS:22 CAMINO COURTTELEPHONE:
(925) 930-8860
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 4DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Li Lingling & Linda KuriharaTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) and Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with staff Li Lingling and Jeanette Sumiran , and informed the purpose of visit, while conducting facility tour, Administrator Linda Kumihara joined LPA on facility tour. Facility has census of 3.

LPA started the inspection with Jeanette continued with Linda . LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen, backyard and side yard and garage. Facility do not have enough supplies of PPEs, but has sufficient paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every 30 days.

Water temperature was tested in one of the bathrooms and measured at 105 degrees Fahrenheit.

LPA observed the following;
1. "No Visitors Allowed" poster by the front door.
2. Facility do not have COVid19 posters around the facility and front door
3. Facility staff was not trained regarding proper Don/Doff of PPE (infection prevention measures)
4. Facility do not have enough PPE supplies (gowns & face shield)



.....Continued to LIC809C....

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 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: LAFAYETTE CARE HOME II
FACILITY NUMBER: 075601371
VISIT DATE: 06/11/2021
NARRATIVE
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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 Linda Kumihara.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 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: LAFAYETTE CARE HOME II
FACILITY NUMBER: 075601371
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on interview , the licensee did not comply with the section cited above instaff was not trained regarding proper Don/Doffing and other infection control training regarding covid19 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2021
Plan of Correction
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Facility Administrator will train all staff for proper PPE don/doffing , and other topics related to infection prevention, proof of training document needed to be submitted on or before 6/25/2021.
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: Leslie IboTELEPHONE: 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