079200388-9-26-2022-15-AS-LIBO-CJMUVV-20220926155546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200388
Report Date: 09/26/2022
Date Signed: 09/26/2022 03:55:57 PM

Document Has Been Signed on 09/26/2022 03:55 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:	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:	09/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Shirley Virden, Administrator		TIME COMPLETED:	04:15 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 9/26/2022 at around 1:55 PM, Licensing Program Analyst (LPA) L. 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 and infection control plan. Facility have an approved assisted living waiver. 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 78 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: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

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: 09/26/2022

NARRATIVE

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LPA observed the following:

· LPA observed unlocked medication cabinet, disinfectant spray, kitchen knives and scissors accessible to dementia residents in care. Corrected 9/26/2022.

· No proof of Covid19 training for S1 & S2.

Technical assistance provided for the following:

· Facility needs to conduct daily covid19 assessment for all residents and staff. All screening needs to be documented. S1 acknowledge his understanding on this topic.

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.

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: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2022 03:55 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: BUTTONS ELDERLY CARE LLC	FACILITY NUMBER: 079200388
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(d)(5)

Personnel Requirements - General

(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: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. 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 in Licensee failed to provide proof of covid19 training for all staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2022
	Plan of Correction
1 2 3 4	Administrator agreed to train all staff, a copy of training , names of staff and signature needs to be sent to CCL office by POC date.

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: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/26/2022 03:55 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: BUTTONS ELDERLY CARE LLC	FACILITY NUMBER: 079200388
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 licensee failed to lock medication cabinet, disinfectant spray, kitchen knives and scissors which was accessible to dementia residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/26/2022
	Plan of Correction
1 2 3 4	Administrator locked the medication cabinet, locked disinfectant sprays , kitchen knives and scissors. Administrator agreed to conduct in service training for all staff, copy of training, names of staff with signature needs to be submitted to CCL office by 9/27/2022.

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: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

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