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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200001
Report Date: 07/22/2022
Date Signed: 07/22/2022 11:58:02 AM

Document Has Been Signed on 07/22/2022 11:58 AM - 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:
07/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Alma Tubianosa, CaregiverTIME COMPLETED:
12:05 PM
NARRATIVE
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On 7/22/2022 at 11:20AM Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Caregiver, Alma Tubianosa explained the reason for visit. LPA spoke with Administrator, Regina Lim via telephone.

When LPA L. Hall was conducting a complaint investigation (15-AS-20220720083356) on 7/22/2022. During file review LPA observed facility has four (4) clients that are over fifty-nine (59) with one (1) age exception approval. LPA also observed that the four (4) clients medical assessment and appraisal needs and services were not updated.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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 2
Document Has Been Signed on 07/22/2022 11:58 AM - It Cannot Be Edited


Created By: Laura Hall On 07/22/2022 at 11:29 AM
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: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited
CCR
85068.4(g)

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85068.4 Acceptance and Retention Limitations (g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent... the licensee must request an exception...retain the individual. The exception request must be made in accordance with Section 80024. The requirement was not met as evidence by:
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Administrator agreed to submit an age exception for 1 client over age 59 to CCLD by POC date.
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Based on LPA's record review Licensee did not comply with the section cited above in having an age exception for client over 60, which poses a potential health and safety risk to persons in care.
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Type B
07/29/2022
Section Cited
CCR85068.4(c)

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85068.4 (c)When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file: The requirement was not met as evidence by:
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Administrator agreed to submit an updated copy of the appraisal needs/services and medical assessment to CCLD by POC date.
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Based on LPAs record review Licensee did not comply with the section cited above in having an updated appraisal needs/services and medical assessment for overage clients, which poses a potential health and safety risk to persons in care.
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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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022


LIC809 (FAS) - (06/04)
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