Community Care Licensing

Type A

Section Cited

CCR

87309(a)

(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 in unlocked under restroom sink, in the hall closet, laundry room, and inside kitchen drawers and cabinets with knives and other sharps, as well as laudry cleaners, cleaning supplies, and mouthwash, which pose an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2022
	Plan of Correction
1 2 3 4	Move all items of danger to locked locations or add locking mechanisms to current locations.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 due to the doors not closing into the garage from the interior and exterior of the facility, refuse in the backyard, unlocked shed with tools and cleaners, and broken slat on deck, which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/04/2022
	Plan of Correction
1 2 3 4	Repair doors into the garage, lock storage shed with tools and cleaners, remove refuse from all areas of the backyard, and repair broken slat on deck. Send proof of repairs to LPA.

Type B

Section Cited

HSC

1569.695(a)(2)

1569.695 Emergency Plans (a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is notavailable, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above through written plans or preparation of supplies, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/28/2022
	Plan of Correction
1 2 3 4	Written Emergency Disaster Plan for facility and obtain adequate emergency water, and at least a 5,000 watt power generator and fuel. Send updated plan and proof of purchase by POC date (delivery not required by POC date).

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022

Type B

Section Cited

CCR

87705(j)

87705 CARE OF PERSONS WITH DEMENTIA (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. 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 because NO exits were equipped with a functioning auditory device, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/28/2022
	Plan of Correction
1 2 3 4	Working auditory devices must be installed and functioning in EVERY exits. Proof of functioning devices at each exit must be emailed to LPA by POC due date.

Type B

Section Cited

CCR

87555(b)(9)

87555 GENERAL FOOD SERVICE REQUIREMENTS (b) The following food service requirements shall apply:(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. 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 dating food in refrigerator and that food removed from a larger pack with the expiration date, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/21/2022
	Plan of Correction
1 2 3 4	Date on all opened food and expiration date on all food removed from larger pack or throw it out.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022