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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601262
Report Date: 10/23/2024
Date Signed: 10/23/2024 05:11:29 PM


Document Has Been Signed on 10/23/2024 05:11 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:SHANNEN GUEST HOMEFACILITY NUMBER:
015601262
ADMINISTRATOR:DE LUNA, DIOSDADOFACILITY TYPE:
740
ADDRESS:5727 RUNNING HILLS AVENUETELEPHONE:
(925) 980-1087
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:6CENSUS: 5DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Diosdado De Luna, Licensee/ AdministratorTIME COMPLETED:
05:25 PM
NARRATIVE
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On 10/23/2024 at 11:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Gaye Basilio and explained the purpose of the visit. Licensee/ Administrator, Diosdado De Luna arrived an hour later.

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 10/7/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 118.5 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathroom. First Aid kit is complete. There was no bodies of water observed. Indoor and outdoor passageways were free of obstruction. Last disaster drill was conducted on 10/15/2024.

LPA reviewed 5 residents and 4 staff files starting at 12:00PM. LPA reviewed a sample of resident's medications starting at 3:30PM. LPA interviewed a resident and 2 staff during inspection.

At 12:20PM, LPA observed R3 and R5 does not have current medical assessment on file.

At 12:30PM, LPA observed R2 and R4 have full bed rails. However, both residents are not receiving hospice care. Staff removed full bed rails during inspection.

At 12:53PM, LPA observed two additional facility beds were stored in R5's room. Staff removed the two beds out of R5's room during inspection.

At 1:15PM, LPA observed unlocked medications (insulin pens) in the refrigerator. Administrator ordered a lockbox and provided a receipt to LPA during inspection.
(Continue on LIC809C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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: SHANNEN GUEST HOME
FACILITY NUMBER: 015601262
VISIT DATE: 10/23/2024
NARRATIVE
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At 1:45PM, LPA observed staff (S1, S2, S3, S4) does not have current First Aid training completed.

At 3:30PM, LPA observed R4's MAR (Medication Administration Records) included PRN medication (Senna 8.6mg). However, facility does not have a doctor's order for R4's Senna.

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, civil penalty, 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: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/23/2024 05:11 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: SHANNEN GUEST HOME
FACILITY NUMBER: 015601262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 staff which poses a potential health and safety risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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4
Administrator has agreed to obtain current First Aid training for S1, S2, S3, S4 and submit copies of completion to CCLD by POC date.

Civil penalty of $250 is being assessed for a repeat violation.
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 two residents which poses a potential health and safety risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Administrator has agreed to obtain current medical assessment for R3 and R5 and submit copies to CCLD by POC date.

Civil penalty of $250 is being assessed for a repeat violation.
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: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 10/23/2024 05:11 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: SHANNEN GUEST HOME
FACILITY NUMBER: 015601262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked medications in the refrigerator which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Administrator purchased a lockbox and provided a receipt to LPA during inspection.

Deficiency cleared.
Type A
Section Cited
CCR
87608(a)(5)(B)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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 having full bed rails for residents who are not on hospice care which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Staff removed the full bed rails on R2 and R4's beds during inspection.

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/23/2024 05:11 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: SHANNEN GUEST HOME
FACILITY NUMBER: 015601262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(a)
(a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities, and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having facility beds stored in R5's room which poses a potential personal rights violation to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Staff removed the two facility beds out of R5's room during inspection.

Deficiency cleared.
Type B
Section Cited
CCR
87465(a)(4)
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
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 a doctor's order for R4's Senna which poses a potential health and safety risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Administrator has agreed to obtain doctor's order for R4's medication (Senna) and submit the 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: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5