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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600386
Report Date: 01/16/2024
Date Signed: 01/16/2024 05:49:17 PM


Document Has Been Signed on 01/16/2024 05:49 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:HARTNELL HOME CAREFACILITY NUMBER:
015600386
ADMINISTRATOR:PURUGANAN,VICTORIA C.FACILITY TYPE:
740
ADDRESS:2041 HARTNELL STREETTELEPHONE:
(510) 489-7290
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
01/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Evangeline Fernandez, CaregiverTIME COMPLETED:
06:45 PM
NARRATIVE
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On 01/16/2024 at 10:00am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Evangeline Fernandez, Caregiver, and explained the purpose of the visit. Victoria Puruganan, Administrator arrived at 11:40am. The Administrator currently holds a certificate (#6019519740) that expires on 10/24/2024. 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, common area, garage and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 75 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 146.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguishers were last serviced on 08/16/2023. Emergency Disaster Plan was posted. First aid kit was observed to be complete.

LPA reviewed five (5) residents file and four (4) staff files the files reviewed were complete.

Continued on LIC809C.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
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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Document Has Been Signed on 01/16/2024 05:49 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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having water temperature 146.8 which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/17/2024
Plan of Correction
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Administrator agreed to turn down the hot water heater and provide CCLD with a video of hot water sample by POC date.
Type A
Section Cited
CCR
87309(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above having WD-40, hammer screw driver, scissors, fabreze air freshener, purell disinfectant, and screw drivers in unlocked drawers located in the kitchen, dining room and office area which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/17/2024
Plan of Correction
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Administrator agreed to lock and keep WD-40, hammer screw driver, Tylenol, melatonin cough and cold medication, scissors, fabreze air freshener, purell disinfectant, and screw drivers locked at all times. Caregiver locked item in a locked cabinet. 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2024 05:49 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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having Tylenol, melatonin, cough and cold medication in unlocked drawers in resident room #1, dining room drawer and kitchen drawer which poses an immediate health and safety to persons in care.
POC Due Date: 01/17/2024
Plan of Correction
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Administrator agreed to keep Tylenol, melatonin, cough and cold medication locked at all times. Administrator also agreed to read and understand the regulation and provide CCLD with self certification by the POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2024 05:49 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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above having meat stored in the freezer in thin produce bags which was freezer burnt and can't be consumed which poses a potential health and safety risk to persons in care.
POC Due Date: 01/23/2024
Plan of Correction
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Administrator agreed to discard freezer burnt food items which were discovered during inspection. Administrator will purchase additional meat and submit photos, conduct an in-service training on food handling and storage, a copy of the in-service training log will be sent to CCLD via email by POC date.
Type B
Section Cited
CCR
80087(a)(c)
(a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above having a bed frame, box spring, microwave, bedrails, weights, nets, paint, ladder and wood planks in the backyard sideyard and behind an unlocked storage unit which poses a potential health and safety risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Administrator agreed to hall away the bed frame, box spring, microwave, bedrails, weights, nets, paint, ladder and wood planks in the backyard sideyard and behind an unlocked storage unit by the POC date and provide CCLD with photos.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2024 05:49 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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(4)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (4) Prior to the use of postural supports that change the ambulatory status of a resident to non-ambulatory, the licensee shall ensure that the appropriate fire clearance, as required by Section 87202, Fire Clearance has been secured.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above by having a dresser blocking a resident in the room which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Administrator shall 1) provide training to staff regarding section cited. 2) provide a log of training with description of training, date, name, and signatures of all staff who received training. 3) Provide a signed statement/certification from Administrator prohibiting the use of such restraints within facility by POC due date.
Type A
Section Cited
CCR
87705(I)(1)(2)
Care of Persons with Dementia: (l)The following initial and continuing requirements shall be met for the Administrator 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. (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above having a locked perimeter fence which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Administrator shall 1) provide training to staff regarding section cited. 2) provide a log of training with description of training, date, name, and signatures of all staff who received training. by POC due date.

Facility is being assess $500 civil penalty for todays 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
Page: 10 of 12


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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386
VISIT DATE: 01/16/2024
NARRATIVE
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Continue from LIC 809

LPA observed the following deficiencies:

· At 10:05am, LPA observed freezer burnt meat stored in thin produce bags.
· At 10:07am, LPA observed medication in an unlocked drawer in the dining room and kitchen.
· At 10:10am, LPA observed WD-40, a hammer, screw drivers, scissors in an unlocked drawer.
· At 10:13am, LPA observed medication in the water temperature in the bathroom 146.8.
· At 10:15am, LPA observed a resident restrained in a bedroom.
· At 10:20am, LPA observed box spring, ladder, paint, wood planks, microwave, weights, nets, bricks and a unlocked storage cabinet.
· At 10:23am, LPA observed a pad lock on the gate.

LPA requested the following documents to be submitted to CCLD by 1/23/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report (updated)
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

Continued on LIC809C.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC809 (FAS) - (06/04)
Page: 11 of 12
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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386
VISIT DATE: 01/16/2024
NARRATIVE
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Continued from LIC809C.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, 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.

*An immediate $500.00 civil penalty will be assessed on today's date for locked gate.*

Exit interview conducted. A copy of the LIC421BG, this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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