015601122-10-20-2023-15-AS-GLUK-CWSU7P-20231020152017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601122
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:20:25 PM

Document Has Been Signed on 10/20/2023 03:20 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:	A NEW HAVEN CARE HOME-SPRINGTOWN		FACILITY NUMBER:	015601122
ADMINISTRATOR:	SOLETA, ARNOLD B.		FACILITY TYPE:	740
ADDRESS:	855 CENTRAL AVENUE		TELEPHONE:	(925) 606-7244
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY:	6	CENSUS: 5	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Robert Abella, Administrator		TIME COMPLETED:	03:35 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 10/20/2023 at 9:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Eljon Palad and explained the purpose of the visit. Administrator, Robert Abella arrived 30 minutes 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 2/9/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 110.9 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. Last fire drill was conducted on 10/3/2023. LPA reviewed 5 resident and 3 staff files starting at 10:10AM. LPA reviewed a sample of resident's medications starting at 12:25PM. LPA interviewed 2 residents and 2 staff at 1:36PM. At 11:00AM, LPA observed R3 does not have TB test result on file during record review. At 11:30AM, LPA observed facility does not have home health written agreement for R2. (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: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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: A NEW HAVEN CARE HOME-SPRINGTOWN	FACILITY NUMBER: 015601122
	VISIT DATE: 10/20/2023

NARRATIVE

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At 1:30PM, LPA observed doctor's order (dated 4/18/2023) for some of R3's medications was different than the actual medications R3 has at the facility. Doctor's order was for Budesonide Inhalation and Albuterol-Ipratropium. However, R3 has Fluticasone Propinate inhaler noted on MAR. LPA observed R3 had an open bottle of Tums Antacid, but does not have a doctor's order.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. 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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/20/2023 03:20 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: A NEW HAVEN CARE HOME-SPRINGTOWN	FACILITY NUMBER: 015601122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2023

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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not following doctor's orders which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	Facility has agreed to contact the doctor and obtain updated doctor's order for R3's list of medications including Tums Antacid, Fluticasone Propionate, Budesonide inhalation (D/C order), and Albuterol-ipratropium (D/C order). Facility will submit proof of contact to CCLD by POC date. Facility will submit updated doctor's order once received from doctor.

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: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/20/2023 03:20 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: A NEW HAVEN CARE HOME-SPRINGTOWN	FACILITY NUMBER: 015601122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

(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 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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having R3's TB test on file which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Facility has agreed to obtain R3's TB test results and submit a copy to CCLD by POC date.

Type B

Section Cited

CCR

87609(b)(4)

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). 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 home health written agreement for R2 which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Facility has agreed to obtain home health written agreement 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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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