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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601252
Report Date: 05/07/2024
Date Signed: 05/07/2024 01:35:39 PM


Document Has Been Signed on 05/07/2024 01:35 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:PLEASANTON SENIOR CARE VILLAFACILITY NUMBER:
015601252
ADMINISTRATOR:NICA, CRISTINAFACILITY TYPE:
740
ADDRESS:2609 CORTE ELENATELEPHONE:
(925) 600-8512
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:6CENSUS: 6DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cristina Nica, AdministratorTIME COMPLETED:
01:50 PM
NARRATIVE
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On 5/7/2024 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Cristina Nica and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, living room, garage, and outdoor area. Smoke and carbon monoxide combination detectors were observed. Fire extinguisher was observed to be full and purchased on 2/21/2024. One week supply of nonperishable and 2-day supply of perishable foods were available. Hot water temperature was measured at 105 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 disaster drill was conducted on 5/2/2024.

LPA reviewed 5 residents and 3 staff files starting at 10:58AM. LPA interviewed 2 residents and 2 staff at starting at 12:10PM. LPA reviewed a sample of resident's medications starting at 12:40PM.

At 12:50PM, LPA observed doctor's order (dated 4/8/2024) for R4's cranberry was for 650mg. However, LPA observed facility has bottle of cranberry 1,400mg for R4. LPA observed R3 has PRN orders for Lactulose and Tylenol, but facility does not have the medications available for R3.

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

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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 05/07/2024 01:35 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: PLEASANTON SENIOR CARE VILLA
FACILITY NUMBER: 015601252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

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 by not having correct medication for R4 and medications available for R3 which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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Administrator has agreed to obtain R4's cranberry 650mg and R4's PRN medications (Lactulose and Tylenol). Administrator will submit a copy of the receipt or picture proof 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: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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