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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601577
Report Date: 09/09/2024
Date Signed: 09/09/2024 01:27:59 PM


Document Has Been Signed on 09/09/2024 01:27 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:RN3 LOVING CARE HOME IVFACILITY NUMBER:
075601577
ADMINISTRATOR:WU, MEINAFACILITY TYPE:
740
ADDRESS:8320 BUCKINGHAM DRIVETELEPHONE:
(510) 439-7063
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:8CENSUS: 7DATE:
09/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Meina WuTIME COMPLETED:
02:00 PM
NARRATIVE
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On 09/09/2024 at 12:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver findings on the allegations above. The LPA informed Meina Wu of the reason for the visit.

During the investigation of complaint 15-AS-20230831144512, it was discovered by the Department that neither the administrator nor the staff had documented Resident R1’s fall in early February 2022. Additionally, neither administrator nor staff had submitted the required unusual incident report (LIC 624) to the Department concerning R1's fall when she sustained a new compression fracture of the T12 vertebrae.

2 Type-A deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 809-D.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
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 2


Document Has Been Signed on 09/09/2024 01:27 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: RN3 LOVING CARE HOME IV
FACILITY NUMBER: 075601577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2024
Section Cited
CCR
87466

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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes . . . when such observation reveals ... a physical health condition ... the licensee shall ensure that such changes are documented ... This requirement is not met as evidenced by:
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A formal conference with CCLD will be scheduled at a later time.
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Record reviews of complaint 15-AS-20230831144512 uncovered that staff had not documented R1's fall in early February 2022, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/10/2024
Section Cited
CCR87211(a)(1)(B)

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87211 Reporting Requirements (a) Each licensee shall furnish ... the Department ...(1) A written report ... within seven days of ... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by:
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A formal conference with CCLD will be scheduled at a later time.
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Record reviews of complaint 15-AS-20230831144512 uncovered that staff had not reported to the Department the injury sustained from R1's fall in early February 2022, which poses an immediate health, safety or personal rights 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) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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