015601469-9-28-2023-15-AS-ADEO-CW44WB-20230927192740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601469
Report Date: 09/27/2023
Date Signed: 09/28/2023 09:06:02 AM

Document Has Been Signed on 09/28/2023 09:06 AM - 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:	LOVING HOME CARE		FACILITY NUMBER:	015601469
ADMINISTRATOR:	GOLDASSIO, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	22270 PERALTA STREET		TELEPHONE:	(510) 582-8839
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	5	CENSUS: 1	DATE:	09/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Matilde Machado/Licensee and Stephanie Goldassio/Administrator		TIME COMPLETED:	07:30 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 this day, September 27, 2023, at 1:30 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Matilde Machado, licensee, and Stephanie Goldassio, administrator, and informed the reason for visit. Facility has Infection Control Plan that was submitted on October 5, 2022. LPA toured the facility inside out with the licensee and administrator, LPA inspected the living room, dining area, kitchen, bedrooms, bathrooms, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Facility has 2 in 1 smoke and carbon monoxide detector at were tested, and observed functional. Hot water temperature in one of the bathrooms was tested, and measured at 117 degrees Fahrenheit. LPA reviewed 4 staff and 1 resident's files, and interviewed 2 staff. Medications checked, and compared with records and doctor's orders. Facility does not handle resident's cash resources/P&I. LPA observed the following: -at 1:52 pm, resident's bed with full bed rails; resident is not on hospice. -at 3:00 pm, no disaster drill record. -at 3:30 pm, 2 staff only have 2 hours of annual training on postural support, restricted health conditions and hospice care -at 4:00 pm, staff (S3 and S4) do not have TB test result on file .....continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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: LOVING HOME CARE	FACILITY NUMBER: 015601469
	VISIT DATE: 09/27/2023

NARRATIVE

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-at 4:10 pm, staff (S1, S2, S3 and S4) do not have LIC501 Personnel Report.
-at 4:15 pm, staff (S3 and S4) do not have LIC503 Health Screening on file.
-at 4:30 pm, resident R1's 6 medications on hand not recorded on LIC622 Centrally Stored Medication and Destruction Record.
-At 4:25 pm, R1's multi vitamins on facility's hand does not match the doctor's order of dosage/strength.

LPA received the following updated/current documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with licensee and administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 09:06 AM - 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: LOVING HOME CARE	FACILITY NUMBER: 015601469
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

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 records review, the licensee did not comply with the section cited above in 2 out of 4 staff having only 2 hours of required training on postural support, restricted health conditions and hospice are which poses a potential safety and/or personal rights risks to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Administrator stated she'll have the staff complete the training. Proof to be submitted by 10/11/23.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above for not having disaster drill record which poses potential safety risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Admininstrator to have drill conducted and keep record. Proof to be submitted by 10/11/23.

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 09:06 AM - 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: LOVING HOME CARE	FACILITY NUMBER: 015601469
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the llicensee did not comply with the section cited above for resident (R1) bed having full bed rails and resident is no longer on hospice which poses a potential personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Administrato stated she'll obtain doctor's order for half bed rails and have the full bed rails replaced. Copy of doctor's order and picture to be submitted by 10/11/23.

Type B

Section Cited

CCR

87506(a)

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 for 6 of resident (R1) medications not recorded on LIC622 Centrally Stored Medication and Destruction Record which poses potential personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Administrator to list all the medications, and submit a self-certification that LIC622 is compteted.

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 09:06 AM - 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: LOVING HOME CARE	FACILITY NUMBER: 015601469
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on recorda review, the licensee did not comply with the section cited above in 2 staff not having TB test and 3 staff with no LIC503 Health Screening records on file which pose a potential health risks to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Administrator to have the 2 staff undergo TB testing and have the LIC503 for the 3 staff completed. Proof to be submitted by 10/11/23.

Type B

Section Cited

CCR

87412(a)

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, licensee did not comply with the section cited above in 4 out of 4 staff not having LIC501 Personnel Record on file which pose a potential personal rights risk to person in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Administrator to have LIC501s completed and submit self-certification by 10/11/23.

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 09:06 AM - 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: LOVING HOME CARE	FACILITY NUMBER: 015601469
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above having a vitamins for R1 with strength different from what's prescribed by the doctor which poses immediate health risk to person in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Administrator to have the right vitamins obtained and submit proof by 9/28/23.

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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