075600076-7-13-2022-15-AS-CLIN-CGASWW-20220713141458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600076
Report Date: 07/13/2022
Date Signed: 07/13/2022 02:15:59 PM

Document Has Been Signed on 07/13/2022 02:15 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:	HAPPY VALLEY-HOME FOR OUR PARENTS		FACILITY NUMBER:	075600076
ADMINISTRATOR:	ONOFREI, NICOLAE		FACILITY TYPE:	740
ADDRESS:	3292 WALNUT LANE		TELEPHONE:	(925) 284-4846
CITY:	LAFAYETTE	STATE: CA	ZIP CODE:	94549
CAPACITY:	6	CENSUS: 5	DATE:	07/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Damaris Onofrei, Administrator		TIME COMPLETED:	02:30 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 7/13/2022 starting at 9:00 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrators Nicolae and Damaris Onofrei and disclosed the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Mitigation Plan and Emergency Disaster Plan on file. THE FOLLOWING DEFICIENCIES WERE OBSERVED: · At approximately 9:05 a.m., LPA's temperature were not checked. LPA was not screened, and staff were not wearing a face covering. · At approximately 9:15 a.m., LPA observed unlocked knives and tools in the kitchen drawers. Unlocked gardening tools were observed in the backyard. · At approximately 9:25 a.m., LPA observed centrally stored medications unlocked and key was left on the lock. Unlocked residents' daily medication boxes were also observed in the top middle drawer right side to the stove. Unlocked bottles of over-the-counter medications were observed in the kitchen cabinet. · At approximately 9:30 a.m., LPA observed unlocked cleaning supplies and laundry detergent in the laundry room where was unlocked.. Continue on LIC809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

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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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: HAPPY VALLEY-HOME FOR OUR PARENTS	FACILITY NUMBER: 075600076
	VISIT DATE: 07/13/2022

NARRATIVE

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· At approximately 9:40 a.m., LPA observed two caregivers have no fingerprint clearance who resided and provided care to residents in facility. Administrator removed them immediately.
· At approximately 10:00 a.m., based on record review and interview, LPA observed R1 was admitted to hospice on 3/16/22, and passed away on 6/25/22. R2 was admitted to hospice on 6/23/22. Administrator admitted that they have not been reported.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Repeating deficiencies and criminal clearance civil penalties are assessed today.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/13/2022 02:15 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: HAPPY VALLEY-HOME FOR OUR PARENTS	FACILITY NUMBER: 075600076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above, knives and tools were unlocked and accessible to residents with dementia which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2022
	Plan of Correction
1 2 3 4	Administrator agreed to keep all items lock at all time, review regulations, and submit photos and self-certification with all staff signatures to CCL by POC due date.

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above, bottles of over-the-counter medications were in the kitchen cabinet and drawer which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2022
	Plan of Correction
1 2 3 4	Administrator agreed to keep them lock at all time, review regulation, and submit photos and self-certification with all staff signaturesto CCL by POC due 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/13/2022 02:15 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: HAPPY VALLEY-HOME FOR OUR PARENTS	FACILITY NUMBER: 075600076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(2)

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above, staff were not wearing mask, didn't check temperature when checking-in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2022
	Plan of Correction
1 2 3 4	Administrator agreed to screen visitors and residents, wear mask in-door, and submit self-certificationall with all staff signatures to CCL by POC due date.

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (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 and interview, the licensee did not comply with the section cited above, centrally stored medicines was unlocked and a key was not removed from the lock which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2022
	Plan of Correction
1 2 3 4	Administrator agreed to keep centrally stored medicines lock at all time, review and understand regulations with staff, and submit photos and self-certification with all staff signaturesto CCL by POC due 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/13/2022 02:15 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: HAPPY VALLEY-HOME FOR OUR PARENTS	FACILITY NUMBER: 075600076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

87355 Criminal Record Clearance (e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in two caregivers who resided and provided care to residents have no criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2022
	Plan of Correction
1 2 3 4	Administrator removed 2 caregivers immediately, and agreed not to have them return until they are cleared to work. Administrator agreed to review and understand the regulations, and submit self-certification to CCL by the POC due 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC809 (FAS) - (06/04)

Page: 12 of 13

Document Has Been Signed on 07/13/2022 02:15 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: HAPPY VALLEY-HOME FOR OUR PARENTS	FACILITY NUMBER: 075600076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above, 2 residents were admitted to hospice were not reported, 1 resident passed away was not reported which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2022
	Plan of Correction
1 2 3 4	Administrator agreed to submit Death Report and Hospice Initiation Notice, also review regulations and submit self-certification to CCL by POC due 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC809 (FAS) - (06/04)

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