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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200784
Report Date: 02/08/2023
Date Signed: 02/08/2023 10:27:18 AM


Document Has Been Signed on 02/08/2023 10:27 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
E BAY DELTA AC/SC, 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: 5DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Meeran Sexena, AdministratorTIME COMPLETED:
10:35 AM
NARRATIVE
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On 2/8/2023 starting at 8:40 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator and disclosed the purpose of the visit.

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 9:20 a.m., LPA observed resident R1 who have dementia didn't have updated physician's report on file, the latest one was dated on 1/25/2021.
· At 9:20 a.m., LPA observed resident R1 who have dementia didn't have updated needs and services plan on file, the latest one was dated on 1/21/2021.

Facility didn't have Infection Control Plan (LIC9282), Administrator will submit the plan to CCL 2/28/2023.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date and/or any repeat deficiencies within a 12-month period may result in additional Civil Penalties.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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Document Has Been Signed on 02/08/2023 10:27 AM - 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: LAFAYETTE GARDENS
FACILITY NUMBER: 079200784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 5 residents who have dementia didn't updated physician's report annually which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2023
Plan of Correction
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Administrator agrees to review regulation section code 87705, and submitted a self-certification of understanding to CCL by the POC due date.
Type B
Section Cited
CCR
87463(c)
87463 Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident’s representative…once every 12 months…
This requirement is not met as evidenced by…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 5 residents didn't update needs and services plan annually on file poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2023
Plan of Correction
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Administrator agrees to review regulation section code 87463, and submit a self-certification of understanding 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) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4