<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019200764
Report Date:
03/19/2024
Date Signed:
03/19/2024 05:59:48 PM
Document Has Been Signed on
03/19/2024 05:59 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:
LIVERMORE VALLEY SENIOR CARE
FACILITY NUMBER:
019200764
ADMINISTRATOR:
DONG, ZHIYONG
FACILITY TYPE:
740
ADDRESS:
3356 EAST AVENUE
TELEPHONE:
(925) 447-5483
CITY:
LIVERMORE
STATE:
CA
ZIP CODE:
94550
CAPACITY:
20
CENSUS:
4
DATE:
03/19/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Elizabeth Nagy, Administrator
Rachell Paniagua, Manager
TIME COMPLETED:
06:15 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 3/19/2024 at 1:45PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with Manager, Rachell Paniagua. Administrator, Elizabeth Nagy arrived 2 hours later. The facility’s fire clearance was approved for 20 non-ambulatory residents of which 10 may be bedridden and 10 residents may be under hospice care.
LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, common areas, and outdoor area. Centrally stored medications were locked in the cabinets. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 5/10/2023. One week supply of nonperishable and 2-day supply of perishable foods were available. Grab bars for each shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction.
LPAs reviewed 4 resident records and 3 staff records starting at 2:50PM. LPAs conducted interviews with 2 residents and 2 staff during inspection. LPAs also reviewed a sample of resident's medications and MAR (Medication Administration Record).
At 2:10PM, LPAs measured hot water temperature at 125.4 degrees F in the hallway bathroom.
At 2:18PM, LPAs observed unlocked cleaning supplies, tools, cigarettes, and staff medications. Staff locked up the items during inspection.
At 2:30PM, LPAs observed no grab bars for toilets in the shared bathrooms and hallway bathroom.
(Continue on LIC809C...)
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Grace Luk
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
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
7
Document Has Been Signed on
03/19/2024 05:59 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:
LIVERMORE VALLEY SENIOR CARE
FACILITY NUMBER:
019200764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
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 having hot water measured at 125.4 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/20/2024
Plan of Correction
1
2
3
4
Facility has agreed to lower hot water and submit picture proof of lowered hot water to CCLD by POC date.
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies, tools, cigarettes, and staff medications which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/20/2024
Plan of Correction
1
2
3
4
Staff locked up the items during inspection.
Deficiency cleared.
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 Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Grace Luk
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
03/19/2024 05:59 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:
LIVERMORE VALLEY SENIOR CARE
FACILITY NUMBER:
019200764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
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. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
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 by not having health screening and TB test for S3 which poses a potential health and safety risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
Facility has agreed to obtain S3's health screening and TB test. Facility will submit documents to CCLD 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Grace Luk
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
03/19/2024 05:59 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:
LIVERMORE VALLEY SENIOR CARE
FACILITY NUMBER:
019200764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.
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 having grab bars for toilets in shared and hallway bathrooms which poses a potential health and safety risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
Facility has agreed to have grab bars for all toilets and submit picture proof to CCLD by POC date.
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 record review, the licensee did not comply with the section cited above by not having current annual trainings for staff which poses a potential health and safety risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
Facility has agreed to obtain and submit current annual trainings for staff to CCLD 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Grace Luk
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
03/19/2024 05:59 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:
LIVERMORE VALLEY SENIOR CARE
FACILITY NUMBER:
019200764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.
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 by not having current needs and service plans for residents which poses a potential health and safety risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
Facility has agreed to obtain and submit current needs and service plans for residents to CCLD 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Grace Luk
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
03/19/2024 05:59 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:
LIVERMORE VALLEY SENIOR CARE
FACILITY NUMBER:
019200764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.
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 by not having admission agreement for R2 which poses a potential health and safety risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
Facility has agreed to obtain and submit admission agreement for R2 to CCLD by POC date.
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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Grace Luk
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
6
of
7
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:
LIVERMORE VALLEY SENIOR CARE
FACILITY NUMBER:
019200764
VISIT DATE:
03/19/2024
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
26
27
28
29
30
31
32
At 3:00PM, LPAs observed R2 does not have admission agreement on file during record review.
At 3:15PM, LPAs observed four residents does not have current needs and service plans on file.
At 3:30PM, LPAs observed S3 does not have health screening and TB test results on file.
At 3:45PM, LPAs observed S2 and S3 does not have current annual training on file.
The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties.
Exit interview conducted with Elizabeth Nagy. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Grace Luk
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
7
of
7