079201239-4-25-2024-15-AS-LHAL-D4NSEJ-20240425134848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201239
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:49:05 PM

Document Has Been Signed on 04/25/2024 01:49 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:	VIRA CARE AT ASPEN		FACILITY NUMBER:	079201239
ADMINISTRATOR:	VAHID, ELVIRA		FACILITY TYPE:	740
ADDRESS:	1111 ASPEN DRIVE		TELEPHONE:	(925) 948-5221
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	6	CENSUS: 5	DATE:	04/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Rodelia Pauligue, Caregiver		TIME COMPLETED:	02:00 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 4/25/2024 at 9:15am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Caregiver, Rodelia Pauligue. LPA spoke with Administrator, Elvira Vahid, via telephone and LPA explained the purpose of the visit. The Administrator currently holds a certificate (#6042528740) that expires on 10/23/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, garage, common area, and back yard. The facility consists of four (4) total bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA 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 124.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors/ carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 1/3/2024. First aid kit was observed to be complete. Fire drill was last conducted on 11/8/2023. Continued on LIC809.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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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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: VIRA CARE AT ASPEN	FACILITY NUMBER: 079201239
	VISIT DATE: 04/25/2024

NARRATIVE

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Continued from LIC809.

Four (4) staff records were reviewed. One (1) staff did not have first aid and health screening. All five (5) resident records were reviewed and complete. LPA reviewed a sample of residents medication.

LPA requested the following documents to be submitted to CCLD by 5/2/2024.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
Resident roster
LIC 610E Emergency Disaster Plan (last page)
Liability Insurance

LPA observed the following deficiencies:

At 10:15am, LPA observed bedroom #1 remodeled. Partial wall and a closet added.
At 10:30am, LPA observed staff sleeping in garage. Two folding cots, clothing, medication, shoes, bedding.
At 10:35am, LPA observed exit gate on left side of house with padlock.
At 10:35am, LPA observed new ADU used for office in backyard.
At 11:45am, LPA observed during record review R4 had prescribed medication that haven't been given.

*An total amount of $500.00 will be cited on today's date for locked gate*

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy the appeal rights and this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/25/2024 01:49 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: VIRA CARE AT ASPEN	FACILITY NUMBER: 079201239
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(6)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: 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 in having R4's medication listed and given which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agreed to add medication to MAR and submit a copy of the MAR to CCLD by POC date.

Type A

Section Cited

CCR

87705(l)(1)

87465 Incidental Medical and Dental Care (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates. 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 exit gate unlocked in case of emergency which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agreed to unlock gate by removing padlock and submit photo to CCLD by POC date. Padlock removed during visit. Deficiency cleared during visit.

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: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/25/2024 01:49 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: VIRA CARE AT ASPEN	FACILITY NUMBER: 079201239
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 in having S3 health screened which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	Administrator agreed to get S3 health screening and submit a copy 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: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/25/2024 01:49 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: VIRA CARE AT ASPEN	FACILITY NUMBER: 079201239
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

87305 Alterations to Existing Building or New Facilities (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 and record review, the licensee did not comply with the section cited above in notifiying CCLD of any alterations which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit a LIC200 and updated facility sketch 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: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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