079200966-5-5-2022-15-AS-JCCR-CE5NMM-20220505103522

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200966
Report Date: 05/05/2022
Date Signed: 05/05/2022 10:35:32 AM

Document Has Been Signed on 05/05/2022 10:35 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	NURTUREHOOD, LLC		FACILITY NUMBER:	079200966
ADMINISTRATOR:	CRUZ, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	2755 CALPINE PL		TELEPHONE:	(925) 890-9007
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	6	CENSUS: 4	DATE:	05/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:32 AM
MET WITH:	Cheisaviviena Verdaguer, Assistant Administrator		TIME COMPLETED:	10:40 AM

NARRATIVE

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On 05/05/2022 at 08:32 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with staff Angelita Villocillo and explained the purpose of the visit. Assistant Administrator Cheisaviviena Verdaguer arrived later to join.

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. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced June 2021. Water temperature was measured at 117.7 degrees F.

The following deficiency was observed during the visit:

LPA observed the staff walking away from the stove range with the back left burner left on.
LPA observed medication unlocked and accessible in the hall closet and in the refrigerator.
LPA observed chemicals unlocked and accessible in the hall closet and under the kitchen sink.

The Facility was cited and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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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Document Has Been Signed on 05/05/2022 10:35 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NURTUREHOOD, LLC	FACILITY NUMBER: 079200966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 chemicals unlocked under the kitchen sink and in the hall closet which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2022
	Plan of Correction
1 2 3 4	The facility will lock up the chemicals. In addition by 5/12/2022, facility will provide staff training with chemical handling an storage. Facility will submit documentation to CCLD with date of training, signature of attendees, and copy training materials.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(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 medication unlocked and accessible in the hall closet and in the refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2022
	Plan of Correction
1 2 3 4	The facility will lock up medications. In addition by 5/12/2022, facility will provide medication training for all staff that administer medication. A copy of receipt will be sent 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 05/05/2022 10:35 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NURTUREHOOD, LLC	FACILITY NUMBER: 079200966
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(d)

Care of Persons with Dementia

(d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia. 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; the staff left the back left burner of the range on and walked away, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2022
	Plan of Correction
1 2 3 4	Administrator shall provide required training to all staff members as it relates to the care of persons with a Dementia and safety modifications. Administrator shall submit copy of topics covered and attendance sheet with all staff signatures to CCLD 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: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC809 (FAS) - (06/04)

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