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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601499
Report Date: 05/25/2023
Date Signed: 05/25/2023 04:38:54 PM


Document Has Been Signed on 05/25/2023 04:38 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 - BERLINFACILITY NUMBER:
015601499
ADMINISTRATOR:ROBERT ABELLAFACILITY TYPE:
740
ADDRESS:1422 BERLIN WAYTELEPHONE:
(925) 784-3842
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
05/25/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Robert Abella/Administrator
and Arnold Soleta/Licensee		TIME COMPLETED:
04:30 PM
NARRATIVE
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On this day, May 25, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 2 complaint (Complaint # 15-AS-20230523113154). LPA was granted entry by staff, Leah Van Alstin, Robert Abella. administrator, arrived after several minutes, followed by Arnold Soleta, licensee. LPA informed the reason for visit. Licensee has to leave and excused himself.

LPA toured the facility inside out with the administrator. LPA inspected including but not limited to living room, dining area, kitchen, ensuite and common bathrooms, kitchen, family room. side and backyard. Hot water temperature in the common bathroom was tested, and measured at 119.5 degrees Fahrenheit.

LPA observed the following:
-At 12:19 p.m. Lysol spray and razor in one of the common bathrooms.
-At 12:21 p.m., 2 bottles Glade spray, resident's (R1) Vicks VapoRub, Desitin cream, Afrin nasal spray,
topical cream, Gold Bond pain and itch relief cream, anti-fungal cream in the other common bathroom
-At 12:27 p.m., Calmoseptin cream, Desitin maximum strength diaper rash paste in 2 resident's bedrooms.
-At 1:15 p.m,, LIC625 for 2 residents were incomplete and/or inaccurate. One has no signature while the other one is dated 12-01-23.
-At 1:30 p.m., staff (S1) record is not at the facility for review. Administrator and LPA asked, S1 stated her file is in her house.


......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
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 4


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
VISIT DATE: 05/25/2023
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation within 12 month of Regulation section 87309(a). This Regulation was cited on February 10, 2023. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with Arnold Soleta over the phone in the presence of Robert Abella.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment. LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/25/2023 04:38 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 - BERLIN
FACILITY NUMBER: 015601499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2023
Section Cited
CCR
87309(a)

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87309 (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:
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Staff removed and locked the items,
Licensee to do in-service training and submit copy of training topic with attendees signatures by 5/26/23,

A $250.00 civil penalty is assessed.
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-Based on observation, the licensee did not comply with the section above for having Lysol and Glade spray, Vicks VapoRub, ointments and creams. razor readilty accessible to residents which pose immediate health and personal rights risks to persons in care, This is a repeat violation,
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 05/25/2023 04:38 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 - BERLIN
FACILITY NUMBER: 015601499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2023
Section Cited
CCR
9888888

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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:
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Administrator to check all the residents' records for completeness and accuracy, and submit a seld-certification by 6/08/23.
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-Based on records review and observation, the licensee did not comply with the section above for resident LIC625 without signatures and dated incorrectly which pose potential personal rights risk to persons in care,
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Type B
06/08/2023
Section Cited
CCR87412(f)

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87412 Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. ....
-This requirement is not met as evidenced by:
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Administrator to the have staff bring back the record. Proof to be submitted by 6/08/23.
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-Based on records review and interview, the licensee did not comply with the section above for S1's file not in the facility which poses potential personal rights risk to persons in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4