015601187-3-25-2024-15-AS-GLUK-D3PUFL-20240325153256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601187
Report Date: 03/25/2024
Date Signed: 03/25/2024 03:33:09 PM

Document Has Been Signed on 03/25/2024 03:33 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:	HRS CARE HOME		FACILITY NUMBER:	015601187
ADMINISTRATOR:	DE LUNA, DIOSDADO		FACILITY TYPE:	740
ADDRESS:	1352 ASTER LANE		TELEPHONE:	(925) 454-3320
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY:	6	CENSUS: 5	DATE:	03/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Diosdado De Luna, Administrator		TIME COMPLETED:	03:50 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 3/25/2024 at 9:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Roy Catilo and explained the purpose of the visit. Administrator, Diosdado De Luna arrived 15 minutes later. The facility’s fire clearance was approved for 6 non-ambulatory residents of which 1 resident 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 1/29/2024. One week of nonperishable and 2-day of perishable food supplies were available. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. First Aid kit is complete. Last fire drill was conducted on 1/15/2024. LPA reviewed 3 residents and 3 staff files starting at 10:45AM. LPA reviewed a sample of resident's medications starting at 1:00PM. LPA interviewed 2 residents and 2 staff at around 2:30PM. At 10:10AM, LPA observed the swimming pool gate was unlocked during inspection. Administrator locked the gate during inspection. Civil penalty of $500 is being assessed. At 10:15AM, LPA observed unlocked knives in the kitchen cabinet. Staff locked up knives during inspection. At 10:30AM, LPA measured hot water temperature at 131.9 degrees F in the hallway bathroom. Staff lowered hot water temperature and LPA re-measured hot water at 107.1 degrees F. At 10:50AM, LPA observed R1, R2, and R3 did not have current medical assessment on file. (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: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

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: HRS CARE HOME	FACILITY NUMBER: 015601187
	VISIT DATE: 03/25/2024

NARRATIVE

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At 11:20AM, LPA observed S4 did not have fingerprint clearance and was at the facility during visit. S4 left the facility during inspection. Civil penalty of $100 is being assessed.

At 11:30AM, LPA observed staff did not have current annual training.

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 with Diosdado De Luna. A copy of this report, civil penalties, 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: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/25/2024 03:33 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: HRS CARE HOME	FACILITY NUMBER: 015601187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above having hot water at 131.9 degrees F which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/26/2024
	Plan of Correction
1 2 3 4	Staff lowered hot water temperature and LPA re-measured hot water at 107.1 degrees F. Deficiency cleared.

Type A

Section Cited

CCR

87307(e)

Personal Accommodations and Services

(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means. 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 having pool gate unlocked during inspection which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/26/2024
	Plan of Correction
1 2 3 4	Staff locked the pool gate during inspection. Civil penalty of $500 is being assessed. Deficiency cleared.

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: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/25/2024 03:33 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: HRS CARE HOME	FACILITY NUMBER: 015601187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above having unlocked knives in the kitchen which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/26/2024
	Plan of Correction
1 2 3 4	Staff locked up the knives during inspection. Deficiency cleared.

Type A

Section Cited

CCR

87355(e)(1)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or 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 having uncleared staff work at the facility which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/26/2024
	Plan of Correction
1 2 3 4	Uncleared staff left the facility and will not return to the facility until fingerprint clearance. Administrator will follow up with Guardian regarding fingerprint clearance for S4 and submit communication to CCLD by POC date. Civil penalty of $100 is being assessed.

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: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/25/2024 03:33 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: HRS CARE HOME	FACILITY NUMBER: 015601187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2024

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above not having current annual training for staff which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain current annual training for staff and provide training documents to CCLD by POC date.

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above not having current medical assessment for three residents which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain current medical assessments for R1, R2, and R3 and will submit copies 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: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC809 (FAS) - (06/04)

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