019200505-5-31-2023-15-AS-LFII-CSCV92-20230531161337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200505
Report Date: 05/31/2023
Date Signed: 05/31/2023 04:13:51 PM

Document Has Been Signed on 05/31/2023 04:13 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:	BELOVED HOME RETREAT		FACILITY NUMBER:	019200505
ADMINISTRATOR:	BYRON TRIPP		FACILITY TYPE:	740
ADDRESS:	41223 CHILTERN DRIVE		TELEPHONE:	(510) 656-9654
CITY:	FREMONT	STATE: CA	ZIP CODE:	94539
CAPACITY:	6	CENSUS: 5	DATE:	05/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Mirriam Paras-Administrator		TIME COMPLETED:	04:25 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	q1On 4/25/2023 starting at 1:10 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with care staff and and explained the purpose of the visit. Administrators certificate (6006422740) is valid and expires on 8/2/2023. The facility’s fire clearance was approved for all six (6) non- ambulatory residents, which facility is granted for two (2) hospice waivers. Upon entry, LPA observed two (2) staff and four (4) residents present during inspection. At 11:02 AM, LPA met and was greeted by Mirriam Paras- Administrator (ADM). Starting at 10:35 AM, LPA toured facility with care staff including but not limited to six (6) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all 5 bedrooms are private and one bedroom is a staff room. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in residents ’ common area bathroom was measured at 119.6 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Sharps were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 4/4/2019. First aid kit was observed to be complete. Continue on Lic809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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: BELOVED HOME RETREAT	FACILITY NUMBER: 019200505
	VISIT DATE: 05/31/2023

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Continued from Lic809

Starting At 11:30 AM, LPA reviewed 3 of 3 staff records. At 12:43 PM, LPA reviewed 4 of 4 residents' record. At 2:05 PM, LPA reviewed a sample of 4 of 4 residents' medications.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

1. At 10:50AM, LPA observed fire extinguisher in common area room expired on 4/4/2019.
2. At 12:30PM, LPA observed S1, S2, and S3 do not have current First aid and CPR training on file.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/5/2023:

· LIC 308- Designation of Administrative Responsibility
· LIC 500- Personnel Report
· LIC 610E- Emergency Disaster Plan (9 Pages)
· Liability Insurance

Exit interview conducted with ADM, appeal rights given along with a copy of this report.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/31/2023 04:13 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: BELOVED HOME RETREAT	FACILITY NUMBER: 019200505
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in not obtaining a current First aid and CPR for S1, S2, and S3. S1 and S2's certificate expired on 5/15/2020, and S3 does not have first aid and CPR training in file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Administrator agree to complete First aid and CPR training for S1, S2, and S3 and to submit proof of training to CCL by POC due date.

Type B

Section Cited

CCR

87203

87203: Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not re-servicing facilities fire extinguisher in common area near the backyard door that expired on 4/4/2019 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/07/2023
	Plan of Correction
1 2 3 4	Administrator agreed to service fire extinguisher in common area room and to submit proof of re-service date shown on receipt of purchase to CCL by POC due 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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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