079200388-9-28-2021-15-AS-LIBO-C7AQZL-20210928123657

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200388
Report Date: 09/28/2021
Date Signed: 09/28/2021 12:47:12 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:	BUTTONS ELDERLY CARE LLC		FACILITY NUMBER:	079200388
ADMINISTRATOR:	SHIRLEY VIRDEN		FACILITY TYPE:	740
ADDRESS:	1448 BUTTONS COURT		TELEPHONE:	(925) 354-9448
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	6	CENSUS: 6	DATE:	09/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	SHIRLEY VIRDEN		TIME COMPLETED:	12:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/28/2021 at around 10:00 AM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Shirley Virden. LPA observed 6 residents during the visit. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. Carbon monoxide and smoke detector was observed to be operational. Facility room temperature was maintained at 70 degrees Fahrenheit. There was at least 7 days of nonperishable and 2 days of perishable foods. Infection control designated leader is the staff Noah Lake. A certified Administrator is on site a minimum of 20 hours a week to oversee proper business operation. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

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: BUTTONS ELDERLY CARE LLC	FACILITY NUMBER: 079200388
	VISIT DATE: 09/28/2021

NARRATIVE

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LPA observed the following:

· Facility DO NOT have adequate 30-day supply of PPE, LPA observed there is only 1 box (20 pcs.) of N95 available during the visit, LPA provided technical assistance. (see notes on LIC812).
· LPA observed sharp container, disinfectant spray & eye drops medication accessible to dementia residents in care. Corrected 9/28/2021.
· LPA observed facility garage that food supplies were stored together with toxic substances.

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 Shirley Virden and Noah Lake.

Exit interview conducted and a copy of this report & appeal rights provided to Administrator.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

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: BUTTONS ELDERLY CARE LLC	FACILITY NUMBER: 079200388
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 LPA observed sharp container, disinfectant spray & eye drops medication accessible to dementia residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2021
	Plan of Correction
1 2 3 4	Adminsitrator need to store sharp container, disinfectant spray & eye drops medication inaccesible to residents in care. Corrected 9/28/2021.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

LIC809 (FAS) - (06/04)

Page: 3 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: BUTTONS ELDERLY CARE LLC	FACILITY NUMBER: 079200388
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(24)

87555 General Food Service Requirements (b) The following food service requirements shall apply: (24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. 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 LPA observed facility garage that food supplies were stored together with toxic substance which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/01/2021
	Plan of Correction
1 2 3 4	Administrator needs to separate food supply storage from toxic supplies.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

LIC809 (FAS) - (06/04)

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