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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600502
Report Date: 02/15/2024
Date Signed: 02/15/2024 04:08:29 PM


Document Has Been Signed on 02/15/2024 04:08 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:MURIEL'S RESIDENTIAL FACILITYFACILITY NUMBER:
015600502
ADMINISTRATOR:JENKINS, IRENE M.FACILITY TYPE:
740
ADDRESS:38880 FLORENCE WAYTELEPHONE:
(510) 703-8248
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 5DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Magdalena Lucero, CaregiverTIME COMPLETED:
04:20 PM
NARRATIVE
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On 2/15/2024 at 12:00pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPAs met with Caregiver Magdalena Lucero, and explained the purpose of the visit. House Manager, Noel Morales, arrived at 12:20pm. Administrator was out-of-the country.

LPAs toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two (2) bathrooms. Staff occupies one (1) bedroom. LPA did not observe any bodies of water. A comfortable temperature is maintained at 71 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 106.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 05/13/2023. Emergency disaster plan last updated 2/1/2024. First aid kit was observed to be complete.

Five (5) staff records were reviewed. None of the staff are CPR trained. LPAs reviewed all five (5) resident records and they were current and complete.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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: MURIEL'S RESIDENTIAL FACILITY
FACILITY NUMBER: 015600502
VISIT DATE: 02/15/2024
NARRATIVE
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Continued from LIC809.

LPA requested the following documents to be submitted to CCLD by 2/22/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (last page)
  • Liability Insurance
  • Resident roster
  • Administrator certificate
  • Updated facility sketch


The following deficiencies were observed:
  • At 12:35pm, LPAs observed during record review none of the staff were CPR trained.
  • At 12:45pm, LPAs observed knives in unlocked cabinet underneath kitchen sink.
  • At 12:50pm, LPAs observed 1/4 gallon of milk, 2 apples, 3 oranges, no fresh vegetables. Facility did not have a 7-day supply of non-perishables and 2 day supply of perishables.
  • At 12:35pm, LPAs observed a hoe, portable toilet, and a chair in back yard on right side of house.
  • At 1:20pm, LPAs observed during record review facility is not maintaining a record of each dose of medication in the resident's record

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: MURIEL'S RESIDENTIAL FACILITY
FACILITY NUMBER: 015600502
VISIT DATE: 02/15/2024
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.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/15/2024 04:08 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: MURIEL'S RESIDENTIAL FACILITY
FACILITY NUMBER: 015600502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(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
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Based on LPAs observation, the licensee did not comply with the section cited above in having knives inaccessible to residents with dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator changed locked during visit. Deficiency cleared
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 02/15/2024 04:08 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: MURIEL'S RESIDENTIAL FACILITY
FACILITY NUMBER: 015600502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation , the licensee did not comply with the section cited above in not maintaining a record of each dose of medication in the resident's record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Administrator agree to record each resident's medication on medical administration record (MAR) for the month of February and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements

(b) The following food service requirements shall apply:

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in not providing a supply of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Administrator agree to purchase food and submit photos and receipts 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 02/15/2024 04:08 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: MURIEL'S RESIDENTIAL FACILITY
FACILITY NUMBER: 015600502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accommodations and Services

(d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in not having passageways outdoor (backyard) free of obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2024
Plan of Correction
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Administrator agree to provide photos to CCLD by POC date.
Type B
Section Cited
CCR
1569.618(c)(3)
§1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling

(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
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Based on LPAs observation], the licensee did not comply with the section cited above in not having at least 1 staff CPR trained per shift which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Administrator agree to have at least 1 staff per shift trained in CPR and provide copy of certification to CCLD by the 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7