079200940-3-15-2023-15-AS-LFRO-CPXW3Q-20230315165618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200940
Report Date: 03/15/2023
Date Signed: 03/15/2023 04:57:00 PM

Document Has Been Signed on 03/15/2023 04:57 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:	NEW ALAMO RESIDENCE HOME		FACILITY NUMBER:	079200940
ADMINISTRATOR:	SAXENA, MEERAN		FACILITY TYPE:	740
ADDRESS:	836 STONE VALLEY RD		TELEPHONE:	(925) 743-1565
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	6	CENSUS: 6	DATE:	03/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Meeran Saxena, Administrator		TIME COMPLETED:	05:15 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 3/15/2023 at 9:30 AM, Licensing Program Analysts (LPAs) L. Francisco and C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Meeran Saxena and explained the purpose of the visit. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden residents. There are 6 residents and 4 staff present during inspection. LPAs toured facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 6 bedrooms are occupied by the residents and 2 bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was serviced on 1/9/2022 Emergency Disaster Plan was last posted on 3/15/2023. First aid kit was observed to be complete. At 11:15 AM, LPAs reviewed 3 staff records and 2 of 3 have current first aid training and at least 1 staff have CPR training per shift. At 1:40 PM, LPA reviewed a sample of resident's medications. *REPORT CONTINUES 809C*

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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 03/15/2023 04:57 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: NEW ALAMO RESIDENCE HOME	FACILITY NUMBER: 079200940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(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. LPAs observed unlocked clorox, drain cleaner and oxy cleaner stored underneath bathroom sink cabinet which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	DEFICIENCY CLEARED DURING VISIT. LPAs observed Administrator removed items and locked it away.

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2) 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked tylenol stored inside medication cabinet in R2's bathroom which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	DEFICIENCY CLEARED DURING VISIT. LPAs observed Administrator removed tylenol and locked it away.

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: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/15/2023 04:57 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: NEW ALAMO RESIDENCE HOME	FACILITY NUMBER: 079200940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 by not completing quarterly drills for each shift which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to conduct a drill with staff for each shift and submit a copy of drill with staff signatures to CCLD.

Type B

Section Cited

CCR

87203

87203 FIRE SAFETY All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 fire extinguisher was last serviced on 1/9/22 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to submit photo 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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: NEW ALAMO RESIDENCE HOME	FACILITY NUMBER: 079200940
	VISIT DATE: 03/15/2023

NARRATIVE

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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
-at 9:58am, LPAs observed Tylenol stored inside medication cabinet in R2's bedroom
-at 10:07am, LPAs observed unlocked clorox, drain cleaner, and oxyclean underneath bathroom sink
-at 10:28am, LPA observed R3's sliding screen door is off track and in disrepair.
-at 11:50am, LPA observed S1's first aid training expired December of 2020
-at 12:15pm, LPA observed quarterly drill was last completed in 2019.
-at 12:25pm, LPA observed residents records are not maintained and available to LPAs.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/31/2023

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

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

Exit interview conducted. Appeal Rights and a copy of this report provided.

LPA will return for annual continuation at a later time.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/15/2023 04:57 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: NEW ALAMO RESIDENCE HOME	FACILITY NUMBER: 079200940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411(c)(1) Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. LPAs observed S1's first aid expired in December of 2020 and S1 stated S1 provides care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to send a copy of S1's first aid certificate.

Type B

Section Cited

CCR

87506(a)

RESIDENT RECORDS (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 by not having all residents records maintained and available to LPAs which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to maintain residents record at facility and submit self certification letter 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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