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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600811
Report Date: 01/17/2024
Date Signed: 01/17/2024 06:49:31 PM


Document Has Been Signed on 01/17/2024 06:49 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:KENNEDY GUEST HOMEFACILITY NUMBER:
015600811
ADMINISTRATOR:JOYCELYN SILLAFACILITY TYPE:
740
ADDRESS:2636 KENNEDY STREETTELEPHONE:
(925) 449-0145
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:6CENSUS: 4DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Joycelyn Castro Silla, AdministratorTIME COMPLETED:
07:00 PM
NARRATIVE
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On 1/17/2024 at 1:40PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Violeta Butardo and explained the purpose of the visit. Administrator, Joycelyn Castro Silla arrived a hour later. The facility’s fire clearance was approved for 6 non-ambulatory residents of which 2 residents maybe under hospice care.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 12/18/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 108.3 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete.

LPA reviewed 4 residents and 2 staff files starting at 2:35PM. LPA reviewed a sample of resident's medications starting at 4:30PM. LPA interviewed 2 residents and 2 staff at 5:20PM.

At 2:50PM, LPA observed R1, R2, and R3 does not have current medical assessment on file.

At 3:00PM, LPA observed R1, R2, R3, and R4 does not have current needs and service plan on file.

At 3:10PM, LPA observed R2 does not have TB test result on file.

At 3:30PM, LPA observed S2 does not have current first aid training.

At 3:50PM, LPA observed S2 does not have current annual training.
(Continue on LIC809C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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 01/17/2024 06:49 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: KENNEDY GUEST HOME
FACILITY NUMBER: 015600811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current annual training for S2 which poses a potential health and safety risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator has agreed to obtain current annual training for S2 and submit training completion to CCLD by POC date.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having TB test result for R2 which poses a potential health and safety risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator has agreed to obtain TB test for R2 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2024 06:49 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: KENNEDY GUEST HOME
FACILITY NUMBER: 015600811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current needs and service plans for residents which poses a potential health and safety risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator has agreed to obtain current needs and service plans for R1, R2, R3, and R4. Administrator will submit copies to CCLD by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not conducting disaster drill at least quarterly which poses a potential health and safety risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator has agreed to conduct a disaster drill and submit document 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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


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: KENNEDY GUEST HOME
FACILITY NUMBER: 015600811
VISIT DATE: 01/17/2024
NARRATIVE
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At 4:10PM, LPA observed facility have not completed a disaster drill at least quarterly for each shift.

At 5:40PM, LPA observed R1's medication (Levothyroxine 25mcg) was given 1.5 tablets according to R1's MAR. However, doctor's order states that medication (Levothyroxine 25mcg) should be given 2 tablets. R1 has doctor's order for Warfarin 2.5mg or 5mg for week of 1/3/2024 and 1/11/2024. However, LPA observed staff gave the incorrect dosage on 5 of those days.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/17/2024 06:49 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: KENNEDY GUEST HOME
FACILITY NUMBER: 015600811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current medical assessment for residents which poses a potential health and safety risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator has agreed to obtain current medical assessment for R1, R2, and R3 and will submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current first aid training for S2 which poses a potential health and safety risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator has agreed to obtain first aid training for S2 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 01/17/2024 06:49 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: KENNEDY GUEST HOME
FACILITY NUMBER: 015600811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can 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: (2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above not following doctor's orders when giving R1's medications which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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Administrator has agreed to notify R1's doctor of the medication error for R1's Levothyroxine and Warfarin. Administrator has agreed to conduct training to staff who administer medications to residents and submit staff sign in sheet to CCLD by 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6