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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601016
Report Date: 11/21/2023
Date Signed: 11/21/2023 03:10:24 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/21/2023 03:10 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: 1DATE:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Noupane Temple, AdministratorTIME COMPLETED:
03:20 PM
NARRATIVE
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On 11/21/2023 at 1:10pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Noupane Temple, Administrator, and explained the purpose of the visit.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) bedrooms and three (3) bathrooms. No bodies of water was observed. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 128.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/13/2023. First aid kit was observed to be complete.

LPA reviewed three (3) staff files and two (2) files were incomplete, and all three (3) staff was not first aid or CPR certified. LPA also reviewed the resident file and it was current and complete.

Continued on LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 9


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
VISIT DATE: 11/21/2023
NARRATIVE
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Continued from LIC809.

LPA observed the following deficiencies:
  • At 1:35pm, LPA observed unlocked cabinet containing medication.
  • At 1:50pm, LPA observed shovels, pressure washer, freezer, and a mattress in back yard.
  • At 2:00pm, LPA during record review staff files were incomplete.
  • At 2:05pm, LPA observed none of the staff were first aid or CPR certified.

LPA requested the following documents to be submitted to CCLD by 12/04/2023.
  • Resident Roster
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (9 pages)
  • Liability Insurance


Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 11/21/2023 03:10 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: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2023
Section Cited
CCR
87465(h)(2)

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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.
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Administrator immediately locked medications in cabinet. Deficiency cleared during visit.
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Based on observation Licensee did not comply with the section cited above in having medications inaccessible to residents which poses an immediate health and safety risk to persons in care.
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Type B
12/06/2023
Section Cited
CCR87705(f)(2)

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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... gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidence by:
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Administrator agreed to remove items and submit picture to CCLD by POC date.
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Based on observation Licensee did not comply with the section cited above in having gardening tools, freezer, , pressure washer, and mattress inaccessible and blocking passageway, 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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
Page: 8 of 9


Document Has Been Signed on 11/21/2023 03:10 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: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
CCR
87412(a)

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87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidence by:
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Administrator agreed to complete all staff files and submit a self-certification that files are completed to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having all staff files complete, which poses a potential health and safety risk to persons in care.
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Type B
12/06/2023
Section Cited
CCR87411(c)(1)

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87411 Personnel Requirements - General (c) ...staff who assist residents with personal activities of daily living shall receive initial and annual training... (1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidence by:
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Administrator agreed to get all staff first aid certified and 1 staff per shift CPR certified and submit a copy of the certifications to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in having staff first aid certified, 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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
Page: 9 of 9