Community Care Licensing

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023

Document Has Been Signed on 01/13/2023 07:56 PM - It Cannot Be Edited

FACILITY NAME: CARELINK ASSISTED LIVING	FACILITY NUMBER: 079201005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2023

Type B

Section Cited

CCR

87203

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 in 1 out of 1 fire extinguishers that have not been serviced or replaced within the past 1 year, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2023
	Plan of Correction
1 2 3 4	Licensee shall replace or have serviced the fire extinguisher and send documentation to LPA on or before the due date.

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: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023

Document Has Been Signed on 01/13/2023 07:56 PM - It Cannot Be Edited

FACILITY NAME: CARELINK ASSISTED LIVING	FACILITY NUMBER: 079201005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2023

Type A

Section Cited

CCR

87465(h)(2)

(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 in 1 out of 1 medication storage areas, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/14/2023
	Plan of Correction
1 2 3 4	Cleared during inspection.

Type A

Section Cited

CCR

87705(f)(1)

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/14/2023
	Plan of Correction
1 2 3 4	Cleared during inspection.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023

Document Has Been Signed on 01/13/2023 07:56 PM - It Cannot Be Edited

FACILITY NAME: CARELINK ASSISTED LIVING	FACILITY NUMBER: 079201005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2023

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/14/2023
	Plan of Correction
1 2 3 4	Cleared during inspection.

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: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023

Document Has Been Signed on 01/27/2023 09:38 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/25/2023 11:12 AM

FACILITY NAME: CARELINK ASSISTED LIVING	FACILITY NUMBER: 079201005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2023

Type B

Section Cited

CCR

87305(a)

Prior to construction or alterations, all facilities shall obtain a building permit. 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 the garage, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2023
	Plan of Correction
1 2 3 4	So long as the new construction in the garage continues to be used for storage purposes only, the Licensee may leave it intact. What the Licensee does need to do is to (1) remove any bedding from the bed and (2) attest to it never again being used as a bedroom in the future.

Type B

Section Cited

CCR

87307(a)(2)(B)

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Citation code above is incorrect. It is amended to Section 87307(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. Based on observation, the licensee did not comply with the section cited above in the living room where caregivers were using it as a sleeping area, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2023
	Plan of Correction
1 2 3 4	Plan of Correction (POC) completed on 01/24/2023. Original POC: On or before the due date, Licensee will attest to the LPA of having made these corrections: (1) caregivers using it as a sleeping area permanently stop using it as a sleeping area and stay elsewhere during the night and (2) Licensee may leave room divider curtain between dining and living rooms so long as she attests to it never again being used as a sleeping area.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023

Document Has Been Signed on 01/13/2023 07:56 PM - It Cannot Be Edited

FACILITY NAME: CARELINK ASSISTED LIVING	FACILITY NUMBER: 079201005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2023

Type B

Section Cited

HSC

1569.618(c)(3)

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 in 2 of 2 caregivers who were not CPR trained, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2023
	Plan of Correction
1 2 3 4	Licensee will get the proper CPR training for the caregivers on or before the due date and send proof of completing the training to the LPA.

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: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023

Document Has Been Signed on 01/13/2023 07:56 PM - It Cannot Be Edited

FACILITY NAME: CARELINK ASSISTED LIVING	FACILITY NUMBER: 079201005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2023

Type B

Section Cited

CCR

87705(h)

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. 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 2 out of 2 gates which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2023
	Plan of Correction
1 2 3 4	Licensee shall have the gates repaired so that they can be opened from outside of the facility and be self-closing and send documentation to LPA on or before the due date.

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: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023

Document is an Amendment of Original Document on 01/23/2023 12:50 PM

FACILITY NAME: CARELINK ASSISTED LIVING	FACILITY NUMBER: 079201005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2023

Type B

Section Cited

CCR

87705(j)

(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 in 4 out of 4 of the auditory devices on exit doors, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/20/2023
	Plan of Correction
1 2 3 4	Licensee shall repair or replace the auditory devices and send an attestation to the LPA that caregivers have been trained about the importance of keeping them in working order to the LPA on or before the due date.

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: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023