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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019200853
Report Date:
03/26/2024
Date Signed:
03/26/2024 03:08:12 PM
Document Has Been Signed on
03/26/2024 03:08 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 CARE HOME
FACILITY NUMBER:
019200853
ADMINISTRATOR:
SANDHU, SEEMA
FACILITY TYPE:
740
ADDRESS:
1542 PERIDOT DR
TELEPHONE:
(510) 825-2383
CITY:
LIVERMORE
STATE:
CA
ZIP CODE:
94550
CAPACITY:
6
CENSUS:
4
DATE:
03/26/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:20 AM
MET WITH:
Wilson Censon, Caregiver
TIME COMPLETED:
03:25 PM
NARRATIVE
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On 3/26/2024 at 9:20AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Caregiver,
Wilson Censon and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory residents of which 1 may be bedridden and 2 residents may be under hospice care.
LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Centrally stored medications were locked in hallway closet. First Aid kit is complete. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 1/11/2024. One week supply of nonperishable and 2-day supply of perishable foods were available. Hot water temperature was measured at 109.2 degrees F in the hallway bathroom sink. Grab bars for each shower and toilet were installed. Non-skid mats/material were observed. There were adequate lights in each room.
LPA reviewed 4 residents and 3 staff records starting at 10:40AM. LPA conducted interviews with 2 residents and 2 staff during inspection. LPA also reviewed a sample of resident's medications and MAR (Medication Administration Record).
At 10:10AM, LPA observed unlocked knives in backyard and kitchen drawer. There was unlocked lighters and tools in kitchen drawers. Cleaning supplies cabinet was unlocked during inspection. Staff locked up the items and cabinet during inspection.
At 10:20AM, LPA observed room 4's screen door is in disrepair with large holes present. LPA observed dog feces in the backyard in the grass and pathway areas.
At 11:00AM, LPA observed R1, R2, and R3 does not have current needs and service plans on file. (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:
03/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
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
10
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 CARE HOME
FACILITY NUMBER:
019200853
VISIT DATE:
03/26/2024
NARRATIVE
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At 11:10AM, LPA observed R3 and R4 does not have TB test results on file.
At 11:45AM, LPA observed S2 and S3 does not have current first aid training on file.
At 12:00PM, LPA observed S2 and S3 does not have initial or current annual training on file.
At 12:45PM, LPA observed R1 had doctor's order for Vitamin D 4000 units with one soft gel daily. However, LPA observed R1 has a bottle of Vitamin D3 2000 units and R1's MAR stated 1 soft gel given.
At 1:00PM, LPA observed the four resident rooms have baby monitor with audio located near resident's bed and the baby monitor receivers are located in the common area near the dining table.
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 Wilson Censon. 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:
03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
2
of
10
Document Has Been Signed on
03/26/2024 03:08 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 CARE HOME
FACILITY NUMBER:
019200853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/26/2024
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having unlocked knives, tools, cleaning supplies, and lighters at the facility which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/27/2024
Plan of Correction
1
2
3
4
Staff locked up the knives, tools, cleaning supplies, and lighters during inspection.
Deficiency cleared.
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
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 by not following doctor's order when giving R1's medication which poses an immediate health and safety risk to persons in care.
POC Due Date:
03/27/2024
Plan of Correction
1
2
3
4
Facility has agreed to conduct training for staff on medication administration and completing the MAR. Facility will submit training log 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:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
3
of
10
Document Has Been Signed on
03/26/2024 03:08 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 CARE HOME
FACILITY NUMBER:
019200853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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 room 4's screen door in disrepair and dog feces in backyard which poses a potential health and safety risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
1
2
3
4
Facility has agreed to repair screen door in room 4 and clean up the dog feces in the backyard. Facility will 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 training for staff which poses a potential health and safety risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
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2
3
4
Facility has agreed to obtain annual training for S2 and S3 and submit training 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:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
4
of
10
Document Has Been Signed on
03/26/2024 03:08 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 CARE HOME
FACILITY NUMBER:
019200853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
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 initial training for staff which poses a potential health and safety risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
1
2
3
4
Facility has agreed to obtain initial training for S2 and S3 and submit documents of training to CCLD by POC date.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.
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 TB test results for R3 and R4 which poses a potential health and safety risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
1
2
3
4
Facility has agreed to obtain TB test results for R3 and R4 and submit copies of documentation 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:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
5
of
10
Document Has Been Signed on
03/26/2024 03:08 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 CARE HOME
FACILITY NUMBER:
019200853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/26/2024
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 three residents which poses a potential health and safety risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
1
2
3
4
Facility has agreed to obtain current needs and service plan for R1, R2, and R3, and submit copies 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:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
6
of
10
Document Has Been Signed on
03/26/2024 03:08 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 CARE HOME
FACILITY NUMBER:
019200853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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 first aid training for staff which poses a potential health and safety risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
1
2
3
4
Facility has agreed to obtain current first aid training for S2 and S3 and submit copies of completion to CCLD by POC date.
Type B
Section Cited
CCR
87468.2(a)
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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 baby monitors in resident's rooms which poses a potential personal rights risk to persons in care.
POC Due Date:
04/19/2024
Plan of Correction
1
2
3
4
Facility has agreed submit a written plan to install a signal system in place of the baby monitors. Facility will submit plans 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:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
10
of
10