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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601428
Report Date: 01/04/2024
Date Signed: 01/04/2024 02:14:04 PM


Document Has Been Signed on 01/04/2024 02:14 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 - HAMPTONFACILITY NUMBER:
015601428
ADMINISTRATOR:SOLETA, ARNOLD B.FACILITY TYPE:
740
ADDRESS:1356 HAMPTON PLACETELEPHONE:
(925) 292-4065
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 6DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nenita Manuel, CaregiverTIME COMPLETED:
02:30 PM
NARRATIVE
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On 1/4/2024 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Caregiver, Nenita Manuel and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory residents of which 3 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 111.8 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 12/5/2023.

LPA reviewed 5 residents and 3 staff files starting at 10:40AM. LPA interviewed 2 residents and 2 staff at 1:10PM. LPA reviewed a sample of resident's medications starting at 1:40PM.

At 11:30AM, LPA observed that R1 does not have a current reappraisal/ needs & service plan on file.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct 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: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
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 01/04/2024 02:14 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 - HAMPTON
FACILITY NUMBER: 015601428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 reappraisal for R1 which poses a potential health and safety risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Facility has agreed to obtain current reappraisal/ needs & service plan for R1 and submit a copy 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: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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