Community Care Licensing

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023

Document Has Been Signed on 04/19/2023 05:45 PM - It Cannot Be Edited

FACILITY NAME: TENDER TOUCH RESIDENTIAL CARE HOME IV	FACILITY NUMBER: 075601526
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2023

Type B

Section Cited

CCR

87203

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 with the fire extinguisher that had not been serviced or replaced within the past 12 months, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/20/2023
	Plan of Correction
1 2 3 4	Licensee purchased and replaced new fire extinguisher to clear deficiency during visit.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023

Document Has Been Signed on 04/19/2023 05:45 PM - It Cannot Be Edited

FACILITY NAME: TENDER TOUCH RESIDENTIAL CARE HOME IV	FACILITY NUMBER: 075601526
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2023

Type B

Section Cited

CCR

87303(a)

80087 BUILDINGS AND GROUNDS (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. 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 in outside fence and gates, inside cabinets and door locks, which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2023
	Plan of Correction
1 2 3 4	Licensee shall repair all inside and outside items and send proof via email to LPA on or before due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023

Document Has Been Signed on 04/19/2023 05:45 PM - It Cannot Be Edited

FACILITY NAME: TENDER TOUCH RESIDENTIAL CARE HOME IV	FACILITY NUMBER: 075601526
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2023

Type B

Section Cited

HSC

1569.311

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. 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 in 1 out of 1 carbon monoxide detectors, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2023
	Plan of Correction
1 2 3 4	Licensee purchased and installed carbon monoxide detector.

Type B

Section Cited

HSC

1569.695(a)(2)

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. 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 in 1 out of 1 emergency water supplies, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2023
	Plan of Correction
1 2 3 4	Licensee must purchase, store, and properly label as "For Emergency Use", the 30 gallons of water needed for a 6 person RCFE and provide picture proof to LPA on or before due date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023