019200863-4-20-2023-15-AS-GLUK-CR42PW-20230420173501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200863
Report Date: 04/20/2023
Date Signed: 04/20/2023 05:35:20 PM

Document Has Been Signed on 04/20/2023 05:35 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:	GRACE HOME CARE II		FACILITY NUMBER:	019200863
ADMINISTRATOR:	DEL ROSARIO, GRACE		FACILITY TYPE:	740
ADDRESS:	663 BRIGHTON WAY		TELEPHONE:	(510) 543-8013
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94551
CAPACITY:	6	CENSUS: 3	DATE:	04/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Grace Del Rosario, Administrator		TIME COMPLETED:	05:50 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 4/20/2023 at 10:35AM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with caregiver, Luisa Tecson. Administrator, Grace Del Rosario arrived 2 hours later. The facility’s fire clearance was approved for 6 non-ambulatory residents and 4 residents may be under hospice care. LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 3/25/2023. One week supply of nonperishable and 2-day supply of perishable foods were available. Hot water temperature was measured at 120 degrees F in the resident's bathroom. LPAs observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. The facility has a written emergency disaster plan. LPAs interviewed 2 residents starting at 11:05AM. LPAs reviewed 3 resident and 2 staff files starting at 11:30AM. LPAs reviewed a sample of resident's medications starting at 3:45PM. LPAs interviewed 1 staff at 4:30PM. At 10:45AM, LPAs observed unlocked medications in the refrigerator. At 11:15AM, LPAs observed outdoor patio walkway was full of items including boxes and furniture. (Continue on LIC9099C...)

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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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Document Has Been Signed on 04/20/2023 05:35 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: GRACE HOME CARE II	FACILITY NUMBER: 019200863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 liability insurance which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/15/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain liability insurance and provide a copy to CCLD by POC date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 a current disaster drill completed which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/15/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to conduct a disaster drill and submit 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: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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: GRACE HOME CARE II	FACILITY NUMBER: 019200863
	VISIT DATE: 04/20/2023

NARRATIVE

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At 12:30PM, LPAs observed facility does not have a current liability insurance. The policy expired in March 2023.

At 12:45PM, LPAs observed facility did not have a current disaster drill. Last disaster drill was completed in 2022.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. 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: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/20/2023 05:35 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: GRACE HOME CARE II	FACILITY NUMBER: 019200863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 cough medicine in the refrigerator which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/21/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain a lockbox and lock the cough medicine in the refrigerator. Administrator has agreed to submit picture proof 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: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 04/20/2023 05:35 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: GRACE HOME CARE II	FACILITY NUMBER: 019200863
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 items obstructing the patio walkway which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to remove or relocate the items and submit picture proof 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: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC809 (FAS) - (06/04)

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