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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601477
Report Date:
05/25/2023
Date Signed:
05/25/2023 01:37:12 PM
Document Has Been Signed on
05/25/2023 01:37 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:
BETS CARE HOME
FACILITY NUMBER:
075601477
ADMINISTRATOR:
LIZA BETS
FACILITY TYPE:
740
ADDRESS:
747 SAN LUIS COURT
TELEPHONE:
(925) 332-8562
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94518
CAPACITY:
4
CENSUS:
1
DATE:
05/25/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:10 AM
MET WITH:
Liza Bets, Licensee
TIME COMPLETED:
01:50 PM
NARRATIVE
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On 05/25/2023 at 09:10 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Licensee Liza Bets and explained the purpose of the visit.
LPA inspected the facility inside and out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced in June 2022.
At 09:32 am LPA reviewed 1 residents record. At 10:02 am, LPA reviewed 3 staff records and 3 of 3 were fingerprint cleared and associated to the facility.
Continued on LIC 809-C...
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/25/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/25/2023
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
8
Document Has Been Signed on
05/25/2023 01:37 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
BETS CARE HOME
FACILITY NUMBER:
075601477
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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 by having trash cans, and other obstacles blocking the emergency exit pathway on the side yard, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2023
Plan of Correction
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The facility will clear pathway and find a new location for the trash cans. Proof of correction will be sent to CCLD by POC date.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(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
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2
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4
Based on record review, the licensee did not comply with the section cited above by having 3 of 3 staff not having current CPR training, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2023
Plan of Correction
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The facility will schedule CPR training for all staff. Proof of correction will be sent to CCLD by POC 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
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/25/2023
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
05/25/2023 01:37 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
BETS CARE HOME
FACILITY NUMBER:
075601477
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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 by not having any medical assessment done since 2019 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2023
Plan of Correction
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The facility will schedule a annual check up for R1 to have a medical assessment. Proof of correction will be sent to CCLD by POC date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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 by not having an record of medications and doasges given to/for R1, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2023
Plan of Correction
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The facility will create a medication log for R1 detailing when, how much and what kind of medication is given to R1. Proof of correction will be sent to CCLD by POC 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
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/25/2023
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
05/25/2023 01:37 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
BETS CARE HOME
FACILITY NUMBER:
075601477
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(1)
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: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.
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 by not having any documentation of perscriptions for R1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2023
Plan of Correction
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The facility will get an updated list of medications from R1s physican including the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. Proof of correction will be sent to CCLD by POC 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
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/25/2023
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
05/25/2023 01:37 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
BETS CARE HOME
FACILITY NUMBER:
075601477
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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Based on observation and interview, the licensee did not comply with the section cited above by having trash piling up on the side of the house along with puppie pads with pee on them on the living room floor, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2023
Plan of Correction
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The facility will remove the puppie pads and dispose of the trash in the side yard. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87506(b)(17)(E)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (E) Section 87463, Reappraisals; and
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 by not having a needs and services plan for R1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2023
Plan of Correction
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The facility will conduce a Reappraisal and document it on an updated needs and services plan. Proof of correction will be sent to CCLD by POC 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
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/25/2023
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
05/25/2023 01:37 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
BETS CARE HOME
FACILITY NUMBER:
075601477
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
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 by not having the PUB 475 20” x 26” in size which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2023
Plan of Correction
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The facility will get and post the PUB 475 in size 20" x 26". Proof of correction will be sent to CCLD by POC 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
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/25/2023
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
05/25/2023 01:37 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
BETS CARE HOME
FACILITY NUMBER:
075601477
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/25/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(5)
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: (5) At least two appropriate shelter locations that can house facility residents during an evacuation. One of the locations shall be outside of the immediate area.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and review, the licensee did not comply with the section cited above by having both secondary shelter locations in the same city as the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2023
Plan of Correction
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3
4
The facility will review the emergency disaster plan and update the secondary locations. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87212(c)
Emergency Disaster Plan
(c) Emergency exiting plans and telephone numbers shall be posted.
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 by not having the current emergency disaster plan posted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2023
Plan of Correction
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2
3
4
The facility will post the current emergency disaster plan. Proof of correction will be sent to CCLD by POC 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
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/25/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/25/2023
LIC809
(FAS) - (06/04)
Page:
7
of
8
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:
BETS CARE HOME
FACILITY NUMBER:
075601477
VISIT DATE:
05/25/2023
NARRATIVE
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...Continued from LIC 809
The following TAs were observed:
The emergency disaster plan has not been reviewed since 2019
There is no medication list for emergencies
There is no needs and services plan for emergencies
The following deficiency was observed during the visit:
Trash in the side yard
pathway blocked in the side yard
There is no staff with current CPR training
R1 does not have an updated medical assessment
R1 does not have updated needs and service plan
The facility does not have the correct size of compliance poster
There is no record of medication or dosages given to R1
There is no record of prescriptions given to R1
The emergency plan only has secondary locations in the same city
The current emergency disaster plan is not posted
The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/25/2023
LIC809
(FAS) - (06/04)
Page:
8
of
8