019200660-9-12-2023-15-AS-GCLK-CVLVQS-20230912163850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200660
Report Date: 09/12/2023
Date Signed: 09/12/2023 04:39:01 PM

Document Has Been Signed on 09/12/2023 04:39 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:	VERMONTCARE LLC		FACILITY NUMBER:	019200660
ADMINISTRATOR:	MAGLONG, ROSELI P		FACILITY TYPE:	740
ADDRESS:	865 VERMONT STREET		TELEPHONE:	(510) 835-3632
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94610
CAPACITY:	10	CENSUS: 5	DATE:	09/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Roseli Maglong, Adminstrator		TIME COMPLETED:	04:45 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 9/12/23 at 2:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Roseli Manglong and explained the purpose of the visit. The facility’s fire clearance was approved for 10 clients of which 10 may be non-ambulatory. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms of which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 107.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 8/10/23. Emergency Disaster Plan was last posted on 1/14/23. First aid kit was observed to be complete. Fire drill was last conducted on 6/15/23. At 2:15 p.m., LPA reviewed 5 residents records, the records were complete. At 3:30 p.m., LPA reviewed a sample of resident’s medications. *Report continues on LIC809C*

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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: VERMONTCARE LLC	FACILITY NUMBER: 019200660
	VISIT DATE: 09/12/2023

NARRATIVE

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***Report continues from LIC809***

At 3:20 p.m., LPA observed pre-poured medications on the kitchen counter in a plastic cup with a resident’s name on it. LPA was told the meds were the resident's PM meds.

At 3:40 p.m. LPA requested to review staff files. LPA was told by the administrator that the files were not at the facility.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in Civil Penalties.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/19/23: LIC610E Emergency Disaster Plan

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2023 04:39 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: VERMONTCARE LLC	FACILITY NUMBER: 019200660
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. The staff files were not available for the LPA to review which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Administrator will send confirmation to LPA that the staff files are in the facility by POC date.

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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. LPA observed pre-poured medications on the kitchen counter in a plastic cup which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/15/2023
	Plan of Correction
1 2 3 4	Administrator will review the above regulation, train the staff and send proof of training to LPA by POC 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: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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