079201027-9-25-2024-15-AS-AGOZ-D9FRTX-20240925131905

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201027
Report Date: 09/25/2024
Date Signed: 09/25/2024 01:29:09 PM

Document Has Been Signed on 09/25/2024 01:29 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	NAVAJO CARE HOME		FACILITY NUMBER:	079201027
ADMINISTRATOR:	CHAUDHRY, TAYYABA		FACILITY TYPE:	740
ADDRESS:	3 NAVAJO COURT		TELEPHONE:	(925) 433-6000
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	6	CENSUS: 6	DATE:	09/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Tayyaba Chaudhry, Administrator		TIME COMPLETED:	01:50 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 9/25/2024 at 9:10 AM, Licensing Program Analyst (LPAs) A. Gomez and P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Tayyaba Chaudhry and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory of which one may be bedridden in room 3. LPAs toured facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is 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 78 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 117.8 degrees Fahrenheit. 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 last serviced on 01/10/2024. Emergency Disaster Plan was last posted on 01/01/2024. First aid kit was observed to be complete. Emergency disaster drill and fire drill was last conducted on 07/28/2024. At 10:30 am, LPA reviewed 6 residents records. At 11:15 am, LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. Report Continues on LIC 809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

Document Has Been Signed on 09/25/2024 01:29 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NAVAJO CARE HOME	FACILITY NUMBER: 079201027
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 having a full bed rail in R6's room. Administrator does not have an exception for full bed rails and was unable to locate physician's order which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	The bed rail was removed during the visit. POC cleared.

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: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NAVAJO CARE HOME	FACILITY NUMBER: 079201027
	VISIT DATE: 09/25/2024

NARRATIVE

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THE FOLLOWING DEFICIENCY WERE OBSERVED DURING VISIT:

At 10:30 am, LPAs observed a full bed rail in R6's room. Administrator removed the bottom rails, POC cleared.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/02/2024:
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

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

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

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

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