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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200001
Report Date: 11/15/2023
Date Signed: 11/15/2023 03:51:19 PM

Document Has Been Signed on 11/15/2023 03:51 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:SPRINGHILL HOMEFACILITY NUMBER:
079200001
ADMINISTRATOR:REGINA D. LIMFACILITY TYPE:
735
ADDRESS:1387 SPRINGHILL DRIVETELEPHONE:
(925) 427-7870
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
11/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Alma Tubianosa, CaregiverTIME COMPLETED:
04:00 PM
NARRATIVE
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On 11/15/2023 at 1:30pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Alma Tubianosa, Caregiver, and explained the purpose of the visit. The administrator currently holds a certificate (#6006493735) that expires on 11/18/2024.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) total bedrooms and two (2 ) bathrooms. Two (2) bedrooms are occupied by staff. Pool in back yard is covered. A comfortable temperature for clients is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 121.3 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 11/7/2022. Fire drill last conducted 4/30/2021. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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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: SPRINGHILL HOME
FACILITY NUMBER: 079200001
VISIT DATE: 11/15/2023
NARRATIVE
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Continued from LIC809.

LPA reviewed all six (6) client records. The three (3) of the clients do not have a current physician's report and appraisal needs and services plan that is required. LPA reviewed four (4) staff files and three (3) of four (4) did not have first aid or CPR.

LPA observed the following deficiencies:
  • At 2:00pm, LPA observed R1, R2, and R3 did not have a current physician's report or appraisal needs and services plan.
  • At 2:25pm, LPA observed S2, S3, and S4 did not have first aid or CPR certification.
  • At 2:40pm, LPA observed a window, a large piece of broken glass, chairs and bed rails in back yard. LPA also observed chairs and walkers blocking exit door from bedroom #3.
  • At 2:45pm, LPA observed facility has not conducted a fire drill since 4/30/2021.


LPA requested the following documents to be submitted to CCLD by 11/22/2023.
  • Client roster
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • LIC 610D Emergency Disaster Plan (9 pages)
  • Updated facility sketch


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/15/2023 03:51 PM - It Cannot Be Edited


Created By: Laura Hall On 11/15/2023 at 03:24 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: SPRINGHILL HOME
FACILITY NUMBER: 079200001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 in having items in back yard that could cause danger or injury to clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
1
2
3
4
Administrator agreed to discard all items and submit photo to CCLD by POC date.
Type B
Section Cited
CCR
80020(c)
Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in conducting a quarterly fire drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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2
3
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Administrator agreed to conduct fire drill and submit sign-in sheet 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
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2023 03:51 PM - It Cannot Be Edited


Created By: Laura Hall On 11/15/2023 at 03:24 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: SPRINGHILL HOME
FACILITY NUMBER: 079200001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having staff first aid certified and CPR trained which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2023
Plan of Correction
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2
3
4
Administrator agreed to have staff first aid certified and to make sure that one staff per shift is CPR certified. A copy of the certification will be submitted to CCLD by POC date.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having and updated needs and services plan for five clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2023
Plan of Correction
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Administrator agreed to complete an updated needs and services plan for each client and submit a self-certification stating that it ha been completed 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
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/15/2023 03:51 PM - It Cannot Be Edited


Created By: Laura Hall On 11/15/2023 at 03:25 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: SPRINGHILL HOME
FACILITY NUMBER: 079200001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(e)
85068.4 Acceptance and Retention Limitations

(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having residents over age 60 with a current physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2023
Plan of Correction
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3
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Administrator agreed to get R1, R2, and R3 a current physician's report and submit copy to CCLD by POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


LIC809 (FAS) - (06/04)
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