Community Care Licensing

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023

Document Has Been Signed on 08/11/2023 04:43 PM - It Cannot Be Edited

FACILITY NAME: GRACE HOME CARE - LLOYD	FACILITY NUMBER: 019201066
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

Type A

Section Cited

CCR

87309(a)

(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 and gardening tools accessible which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/14/2023
	Plan of Correction
1 2 3 4	Staff locked up the cleaning supplies and gardening tools 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, the licensee did not comply with the section cited above by not having the correct Ferrous Sulfate supplement available which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/14/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain the Ferrous Sulfate 325mg supplement and submit picture proof to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023

Document Has Been Signed on 08/11/2023 04:43 PM - It Cannot Be Edited

FACILITY NAME: GRACE HOME CARE - LLOYD	FACILITY NUMBER: 019201066
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

Type B

Section Cited

CCR

87411(f)

(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 S2's health screening which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain S2's health screening and submit a copy to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023

Document Has Been Signed on 08/11/2023 04:43 PM - It Cannot Be Edited

FACILITY NAME: GRACE HOME CARE - LLOYD	FACILITY NUMBER: 019201066
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

Type B

Section Cited

HSC

1569.69(a)(2)

(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 medication training for S2 which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to conduct medication training for S2 and submit training document to CCLD by POC date.

Type B

Section Cited

HSC

1569.695(c)

(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 conducting an emergency drill every 3 months which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to conduct an emergency drill and submit completion document to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023

FACILITY NAME: GRACE HOME CARE - LLOYD	FACILITY NUMBER: 019201066
	VISIT DATE: 08/11/2023

FACILITY NAME: GRACE HOME CARE - LLOYD	FACILITY NUMBER: 019201066
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

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 S1 which poses a potential health and safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain current first aid training for S1 and submit completion document to CCLD by POC date.

Type B

Section Cited

CCR

87506(d)

(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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 incomplete files for R2 and R3 which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain R2 and R3's complete file and have it available at the facility for any future reviews. Administrator will submit self-certification to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023