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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601016
Report Date: 07/03/2024
Date Signed: 07/03/2024 05:30:26 PM


Document Has Been Signed on 07/03/2024 05:30 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:SIVILAY ELDERLY HOME CAREFACILITY NUMBER:
075601016
ADMINISTRATOR:TEMPLE, NOUPANEFACILITY TYPE:
740
ADDRESS:2242 MT. WHITNEY DRIVETELEPHONE:
(925) 709-0956
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 5DATE:
07/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Noupane Temple, AdministratorTIME COMPLETED:
05:45 PM
NARRATIVE
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On 7/3/2024 at 3:00pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Noupane Temple, Administrator, and explained the purpose of the visit.

LPA received a request for a hospice waiver increase on 6/28/2024. LPA was informed the facility had retained the resident before requesting the waiver. LPA will issue a citation for the facility not requesting the waiver before retaining the resident.

The following deficiencies were also observed during the visit:
  • At 3:10pm, LPA observed medications sitting on the kitchen table and counter top. LPA also observed scissors accessible to residents.
  • At 3:20pm, LPA observed during record review S2 not fingerprinted or associated to the facility.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate $500.00 civil penalty was assessed on today's date for fingerprint*

Exit interview conducted. A copy of the appeal rights, LIC421BG, and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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 07/03/2024 05:30 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: SIVILAY ELDERLY HOME CARE
FACILITY NUMBER: 075601016

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/04/2024
Section Cited
CCR
87355(d)

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87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement... This requirement was not met as evidence by:
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Administrator agreed to have S2 fingerprinted and submit copy to CCLD by POC date.
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Based on record review and observation the Licensee did not comply with the section cited above in having S2 fingerprinted before working, which poses a potential health and safety risk to persons in care.
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Type A
07/11/2024
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical and Dental Care (h)...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... This requirement was not met as evidence by:
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Administrator locked all medications away and made inaccessible. Deficiency cleared during visit.
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Based on record review the Licensee did not comply with the section cited above in requesting a hospice waiver before admitting a hospice resident, which poses a potential health and safety risk to persons in care.
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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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/03/2024 05:30 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: SIVILAY ELDERLY HOME CARE
FACILITY NUMBER: 075601016

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2024
Section Cited
CCR
87632(a)

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87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following: This requirement was not met as evidence by:
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Administrator agreed to read and review regulation 87632 and submit a self-certification that the facility will abide by the regulation going forward to CCLD by POC date.
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Based on observation and interview the Licensee did not comply with the section cited above requesting a hospice waiver from CCLD before retaining a resident, which poses a potential health and safety risk to persons in care.
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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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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