015601095-8-2-2023-15-AS-GLUK-CUC2VP-20230802174416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601095
Report Date: 08/02/2023
Date Signed: 08/02/2023 05:44:24 PM

Document Has Been Signed on 08/02/2023 05:44 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:	HERITAGE ESTATES		FACILITY NUMBER:	015601095
ADMINISTRATOR:	BATTISTI, STEVE		FACILITY TYPE:	740
ADDRESS:	900 E STANLEY BLVD		TELEPHONE:	(925) 373-3636
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY:	65	CENSUS: 56	DATE:	08/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Steve Battisti, Administrator Susan Donaghy, Health & Wellness Director		TIME COMPLETED:	05:50 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 8/2/2023 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Steve Battisti and Health & Wellness Director, Susan Donaghy. The facility’s fire clearance was approved for 65 non-ambulatory residents and 8 residents may be under hospice care. LPA toured the facility with Susan including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 2/1/2023. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food supplies twice a week. Freezer’s temperature was registered at -3 degree F while the refrigerator’s temperature was recorded at 38 degrees F. Hot water temperature was measured at 112.3 degrees F in a resident's bathroom sink. Grab bars and non-skid mats were observed. There were adequate lights in each room. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 7/20/2023. (Continue on LIC809C...)

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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: HERITAGE ESTATES	FACILITY NUMBER: 015601095
	VISIT DATE: 08/02/2023

NARRATIVE

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LPA reviewed 5 resident and 5 staff files starting at 11:45AM. LPA interviewed 4 residents and 4 staff starting at 10:30AM. LPA reviewed a sample of resident's medications starting at 3:45PM.

At 12:45PM, LPA observed S3 does not have health screening and TB test completed.

At 1:00PM, LPA observed S4 does not have current first aid training completed.

At 4:15PM, LPA observed R2 did not have Bengay gel PRN medication available. Record review shows that the gel was in the current MAR. R2 have not used this medication since doctor's order on 6/8/2023.

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

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/02/2023 05:44 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: HERITAGE ESTATES	FACILITY NUMBER: 015601095
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(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 record review, the licensee did not comply with the section cited above by not having health screening and TB test for S3 which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain S3's health screening/TB test 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: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/02/2023 05:44 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: HERITAGE ESTATES	FACILITY NUMBER: 015601095
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above not having PRN medication Bengay gel which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain a new order for this prescription since the Bengay gel has been discontinued and will submit the new order 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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having current first aid training for S4 which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain first aid training for S4 and submit a copy of current first aid training too 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: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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