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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200626
Report Date: 01/10/2024
Date Signed: 01/10/2024 12:15:00 PM


Document Has Been Signed on 01/10/2024 12:15 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:LIMERIDGE SENIOR LIVINGFACILITY NUMBER:
079200626
ADMINISTRATOR:FIEL, JAMES AFACILITY TYPE:
740
ADDRESS:1100 FAIR WEATHER CIRCLETELEPHONE:
(925) 798-8239
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:3CENSUS: 0DATE:
01/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH: Rose Fiel, LicenseeTIME COMPLETED:
12:25 PM
NARRATIVE
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On 01/10/24 at 9:20 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Administrator James and Rose Fiel and explained the purpose of the visit. The facility was opened in 2018 and has never had a residents. They are looking to obtain residents this year. Licensee will inform LPA prior to the facility moving in their first residents.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced in September 2023. At 11:05 am, LPA reviewed 2 staff records and 2 of 2 were fingerprint cleared and associated to the facility.

The following deficiency was observed during the visit:
Laundry room with chemicals left unlocked
facility staff did not have LIC508 on file

The following TA was observed during the visit:
Facility does not have liability insurance

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
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 01/10/2024 12:15 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: LIMERIDGE SENIOR LIVING
FACILITY NUMBER: 079200626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)(B)
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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having the the criminal records clearance in each staff file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2024
Plan of Correction
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The facility agrees to add the criminal records clearance to each staff file. A copy of the criminal records clearance will be sent to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/10/2024 12:15 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: LIMERIDGE SENIOR LIVING
FACILITY NUMBER: 079200626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by leaving the laundry room door unlocked with chemicals accessible which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
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POC cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3