Community Care Licensing

Document Has Been Signed on 01/27/2025 06:18 PM - It Cannot Be Edited

Harpreet Humpal TELEPHONE: (510) 529-9416 James Sampair TELEPHONE: (510) 286-4201 DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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. The maximum hot water temperature was measured at 127.9 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/28/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall attest to LPA in an email that the error has been corrected.

Section Cited

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

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

HSC

1569.153(d)

(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from 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 4 of 4 residents have missing, blank, unsigned, or undated forms which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall attest to LPA in an email to james.sampair@dss.ca.gov that the error has been corrected.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

CCR

87412(a)(11)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 1 of 3 active employees had no health screening, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall attest to LPA in an email to james.sampair@dss.ca.gov that the error has been corrected.

Type B

Section Cited

CCR

87411(d)

(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: 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, with no documentation of training for new or existing employees, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) the error has either been corrected or that as soon as the error has been corrected LPA Sampair will be contacted at james.sampair@dss.ca.gov.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. 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, 0 of 1 new staff member completed new hire training before providing care to residents, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) the error has either been corrected or that as soon as the error has been corrected LPA Sampair will be contacted at james.sampair@dss.ca.gov.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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, 0 of 2 existing staff member completed their annual training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) the error has either been corrected or that as soon as the error has been corrected LPA Sampair will be contacted at james.sampair@dss.ca.gov.

Type B

Section Cited

HSC

1569.626(a)(1)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. 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, 0 of 3 staff members with proof of dementia training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) the error has either been corrected or that as soon as the error has been corrected LPA Sampair will be contacted at james.sampair@dss.ca.gov.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

HSC

1569.626(a)(2)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application. 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, 0 of 3 staff members with proof of dementia training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) the error has either been corrected or that as soon as the error has been corrected LPA Sampair will be contacted at james.sampair@dss.ca.gov.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

HSC

1569.696(a)(1)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. 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, 0 of 3 staff members with proof of dementia training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) the error has either been corrected or that as soon as the error has been corrected LPA Sampair will be contacted at james.sampair@dss.ca.gov.

Type B

Section Cited

HSC

1569.696(a)(2)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (2) Four hours of training thereafter of in-service training per year on the subject of serving those residents. 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, 0 of 2 staff members with proof of training on postural supports, restricted conditions or health services, and hospice care, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) the error has either been corrected or that as soon as the error has been corrected LPA Sampair will be contacted at james.sampair@dss.ca.gov.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

HSC

1569.69(a)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: 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, no medication training documentation for 1 new staff member assisting with the self-administration of medications, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) the error has either been corrected or that as soon as the error has been corrected LPA Sampair will be contacted at james.sampair@dss.ca.gov.

Type B

Section Cited

HSC

1569.69(b)

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. 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, no documentation of annual medication training for 2 of 2 non-Administrator caregivers, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) the error has either been corrected or that as soon as the error has been corrected LPA Sampair will be contacted at james.sampair@dss.ca.gov.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

CCR

87465(h)(5)

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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,1 week of medications stored in dispenser, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	Cleared during inspection.

Section Cited

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

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

CCR

87456(a)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: 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, 4 of 4 residents with missing, unsigned, undated, and/or incomplete documentation: pre-admission appraisal (LIC 603 Preplacement Appraisal Information or LIC 603A Resident Appraisal); LIC 625 Appraisal/Needs and Services Plan, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) the pre-admission appraisal (LIC 603 Preplacement Appraisal Information or LIC 603A Resident Appraisal); LIC 625 Appraisal/Needs and Services Plan has been completed for every resident.

Type B

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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, 0 of 4 residents have documented reappraisals within the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall: (1) attest to LPA in an email that ALL staff have carefully reviewed Title 22 regulations assigned relating to this citation and (2) a reappraisal (603A Resident Appraisal AND LIC 625 Appraisal/Needs and Services Plan) has been completed for every resident.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

CCR

87463(h)

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. 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, 1 of 4 residents have a Physician's Report older than 12 months, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall attest to LPA in an email that either the resident has completed an annual routine visit with a licensed medical professional or that the resident's responsible party has made an appointment for the annual physical to be completed as soon as possible.

Type B

Section Cited

CCR

87463(i)

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, 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, 0 of 4 residents have documented reappraisal meetings with the residents' representative within the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall attest to LPA in an email that either they have completed and documented the in-person or virtual meeting with 4 of the 4 residents' representatives or they have a meeting scheduled with them to be completed as soon as possible.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025

Link to Parent Document Below:

FACILITY NAME: AARON'S ADVANCE CARE HOME INC.	FACILITY NUMBER: 075601497
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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, no disaster/emergency and fire drills are being conducted, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall attest to LPA in an email that a quarterly disaster/emergency and fire drills has been conducted AND all have been scheduled for the rest of 2025.

Type B

Section Cited

HSC

1569.695(d)

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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, no record of LIC 610E being reviewed within the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	On or before the due date, the Licensee shall attest to LPA in an email that the LIC 610E being reviewed and that the final page has been signed that it has been reviewed by Licensee.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 529-9416 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025