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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201082
Report Date: 01/11/2024
Date Signed: 01/11/2024 04:45:22 PM


Document Has Been Signed on 01/11/2024 04:45 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 - MEADOWLARKFACILITY NUMBER:
019201082
ADMINISTRATOR:DEL ROSARIO, GRACEFACILITY TYPE:
740
ADDRESS:538 MEADOWLARK STREETTELEPHONE:
(510) 543-8013
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:6CENSUS: 2DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Grace Del Rosario, Licensee
Amalia Saptang, Caregiver		TIME COMPLETED:
05:00 PM
NARRATIVE
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On 1/11/2024 at 1:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Caregiver, Amalia Saptang and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory residents of which 3 residents maybe under hospice care. Licensee, Grace Del Rosario arrived about two hours later.

LPA 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 extinguisher was observed to be full and last serviced on 3/27/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 119.7 degrees F in the hallway bathroom. LPA 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. Last emergency drill was conducted on 1/1/2024.

LPA reviewed 2 residents and 2 staff files starting at 2:30PM. LPA reviewed a sample of resident's medications starting at 3:30PM. LPA interviewed 2 residents and 1 staff at 3:50PM.

At 3:10PM, LPA observed S2 does not have current annual training on file.

At 3:45PM, LPA observed R1 does not have PRN medication records on file. Licensee created PRN medication records for R1 during inspection.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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 3


Document Has Been Signed on 01/11/2024 04:45 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 - MEADOWLARK
FACILITY NUMBER: 019201082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above by not having current training for S2 which poses a potential health and safety risk to persons in care.
POC Due Date: 01/29/2024
Plan of Correction
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Licensee has agreed to obtain current training for S2 and submit training completion to CCLD by POC date.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having PRN records for R1 which poses a potential health and safety risk to persons in care.
POC Due Date: 01/29/2024
Plan of Correction
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Licensee created PRN records for R1 and has agreed to audit other resident's PRN records. Licensee has agreed to submit written statement of audit completion 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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