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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601499
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:55:56 AM


Document Has Been Signed on 02/10/2023 11:55 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:A NEW HAVEN CARE HOME - BERLINFACILITY NUMBER:
015601499
ADMINISTRATOR:ROBERT ABELLAFACILITY TYPE:
740
ADDRESS:1422 BERLIN WAYTELEPHONE:
(925) 784-3842
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Robert Abella, AdministratorTIME COMPLETED:
12:10 PM
NARRATIVE
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On 2/10/2023 at 10:25AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with caregiver, Leah Van Alstin. Administrator, Roberto Abella arrived 10 minutes later.

Upon entry, caregiver did not conduct COVID screening for LPA. LPA observed visitor's log and hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, garage, and outdoor areas. LPA observed cough etiquette, signs & symptoms, and physical distancing are posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms. Hot water was measured at 111.9 degrees F in the hallway bathroom sink.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. Staff were FIT tested and have certificate card on file. LPA observed PPEs, food, and paper supplies are sufficient.

At 10:40AM, LPA observed key was on the cabinet with staff vitamins and unlocked scissors in the kitchen drawer. There were keys on the hallway closet where the cleaning supplies were kept. LPA observed unlocked electric gardening trimmer in the backyard. Administrator locked up the items during inspection.

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

Exit interview conducted with Roberto Abella. A copy of this report 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: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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Document Has Been Signed on 02/10/2023 11:55 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: A NEW HAVEN CARE HOME - BERLIN
FACILITY NUMBER: 015601499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023

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
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Based on observation, the licensee did not comply with the section cited above by having unlocked scissors in kitchen, key on cabinet with staff vitamins, key on hallway closet with cleaning supplies, and unlocked eletric gardening trimmer in backyard which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/11/2023
Plan of Correction
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Administrator locked up the items and remove keys during inspection.

Deficiency cleared.
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: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
LIC809 (FAS) - (06/04)
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