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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200784
Report Date: 02/18/2022
Date Signed: 02/18/2022 06:17:59 PM


Document Has Been Signed on 02/18/2022 06:17 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:LAFAYETTE GARDENSFACILITY NUMBER:
079200784
ADMINISTRATOR:SAXENA, MEERANFACILITY TYPE:
740
ADDRESS:3486 MONROE AVENUETELEPHONE:
(408) 623-2859
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 6DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Sonora Cruz, Lead CaregiverTIME COMPLETED:
06:30 PM
NARRATIVE
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On 2/18/2022 starting at 3:55 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with lead caregiver Sonora Cruz while Administrator Meeran Saxena was absent. LPA disclosed the purpose of the visit and have Administrator authorize Sonora for the inspection and sign on the report..

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· At 4:20 p.m., LPA observed unlocked centrally stored medications located at the corner of the dinning room. Staff locked it up during inspection.
· At 4:21 p.m., LPA observed unlocked knives in the basket located on the top of refrigerator in the kitchen. Staff couldn't find a place to lock up knives. LPA advised caregiver to lock them up in the medication cabinet for now until Administrator has better solution.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with lead caregiver. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
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 5


Document Has Been Signed on 02/18/2022 06:17 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: LAFAYETTE GARDENS
FACILITY NUMBER: 079200784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care
(h)The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and records review, licensee did not comply with the section cited above. LPA observed centrally stored medications in the dinning room was left unlock which poses an immediate health, safety risk to persons in care.
POC Due Date: 02/19/2022
Plan of Correction
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Caregiver locked up the centrally stored medication during visit.
In addition, Administrator will conduct in-services training with staff of regulation and submit a copy of training agenda and sign-in sheet to CCL by the POC due date.
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA observed unlocked knives in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2022
Plan of Correction
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Caregiver locked up the knives in the centrally stored medication cabinet during visit.
In addition, Administrator will conduct in-services training with staff of regulation and submit a copy of training agenda and sign-in sheet to CCL by the POC due 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5