079200562-9-23-2022-15-AS-PWAN-CJJSDY-20220923134756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200562
Report Date: 09/23/2022
Date Signed: 09/23/2022 01:48:30 PM

Document Has Been Signed on 09/23/2022 01:48 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	GRANNY'S LOVING ANGELS LLC		FACILITY NUMBER:	079200562
ADMINISTRATOR:	BADE, MARIA DARLENE		FACILITY TYPE:	740
ADDRESS:	1000 EL CAPITAN DRIVE		TELEPHONE:	(925) 314-1877
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	6	CENSUS: 6	DATE:	09/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Joan Tungcul, Caregiver		TIME COMPLETED:	02:00 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 09/23/2022 at 10:55 AM, Licensing Program Analysts (LPAs) P. Watson and L. Francisco arrived unannounced to conduct an annual Infection Control Inspection. LPAs met with Cargiver Joan Tungcui and explained the purpose of the visit. LPAs spoke with Administrator on the phone and was told Joan could sign the report. During the Infection Control Inspection, LPAs toured facility with Joan including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, Covid questionnaires, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff. At 11:40 am, LPAs reviewed 4 residents records. At 11:40 am, LPAs reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. Continue on 809 C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRANNY'S LOVING ANGELS LLC	FACILITY NUMBER: 079200562
	VISIT DATE: 09/23/2022

NARRATIVE

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The following deficiency was observed during inspection:
-At approximately 11:10 am LPA's observed a camera in R1 and R2 shared room
- At approximately 11:15 am LPA's observed keys inserted in the centrally stored medicine cabinets and unlocked medication
-At approximately 11:18 am LPA's observed unlocked laundry supplies in the laundry room.
-At approximately 11:20 am LPA's observed unlocked tools and a gas lighter in the garage
-At approximately 11:25 am LPA's observed several portable oxygen tanks without stands in the garage.
-At approximately 11:28 am LPA's observed keys inserted in cabinet where cleaning supplies and knives were being stored
-At approximately 11:30 am LPA's observed eggs sitting out in the kitchen

The following forms are to be updated and submitted to CCLD by 9/30/2022.
- LIC500- Personnel Report
- LIC308- Designation of Administrative Responsibility
- LIC610E- Emergency Disaster Plan
- An updated copy of Administrator certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties

Exit interview conducted and a copy of this report provided along with Appeal rights.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/23/2022 01:48 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRANNY'S LOVING ANGELS LLC	FACILITY NUMBER: 079200562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. 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 by not properly storing eggs in the fridge which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/24/2022
	Plan of Correction
1 2 3 4	Deficiency cleared during visit, LPAs observed staff discharding eggs in the outdoor trash bin. In addition, Administrator will review regulations and conduct training with staff and provide a copy of signitures by 9/30/2022 to CCLD.

Type A

Section Cited

CCR

87705(f)(1)

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 by having unlocked knives, gas lighter, and electric chainsaw which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/24/2022
	Plan of Correction
1 2 3 4	Administrator will review regulations and conduct training with staff and provide a copy of signitures by 9/30/2022 to CCLD.

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: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/23/2022 01:48 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRANNY'S LOVING ANGELS LLC	FACILITY NUMBER: 079200562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 by leaving keys in the centrally stored medicine cabinet, having medications and rubbing alcohol out, and unlocked laundry detergent which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/24/2022
	Plan of Correction
1 2 3 4	Administrator will submit self certification and photos of locked items to CCLD by POC date. In addition, Administrator will review regulations and conduct training with staff and provide a copy of signitures by 9/30/2022 to CCLD.

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: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/23/2022 01:48 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRANNY'S LOVING ANGELS LLC	FACILITY NUMBER: 079200562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(1)

87468.1(a)(1) Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. 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's observed a camera in R1 and R2 shared room which poses a potential personal rights risk to persons in care.
	POC Due Date: 09/28/2022
	Plan of Correction
1 2 3 4	Administrator will obtain a consent letter from family members and send an exception request letter to CCLD by POC date. Effectively immediately Administrator will discontinue use of camera until exception has been approved.

Type B

Section Cited

CCR

87618(b)(3)(E)

87618(b)(3)(E) Oxygen Administration - Gas and Liquid (3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. 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 by not having stands for the portable tanks in the garage which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/28/2022
	Plan of Correction
1 2 3 4	Administrator will obtain stands for all the oxygen tanks and send a photo 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: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

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