079200995-11-6-2023-15-AS-PWAN-CXC2MG-20231106163108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200995
Report Date: 11/06/2023
Date Signed: 11/06/2023 04:31:15 PM

Document Has Been Signed on 11/06/2023 04:31 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	CAREFRONT RESIDENTIAL LIVING, LLC		FACILITY NUMBER:	079200995
ADMINISTRATOR:	WANG, DING		FACILITY TYPE:	740
ADDRESS:	4086 TULARE DR		TELEPHONE:	(925) 890-8953
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 5	DATE:	11/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Ding Wong, Administrator		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/06/2023 at 12:30 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Ding Wong and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory which 1 may be Bedridden. LPA toured facility with Ding including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all 6 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 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 bathrooms were measured within range of 105-120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguishers were observed. First aid kit was observed to be complete. At 12:55 PM, LPA reviewed 5 of 5 residents records. At 2:30 PM, LPA reviewed 4 of 7 staff records and 4 of 4 have first aid training and associated to the facility. At PM, LPA reviewed a sample of 5 of 5 resident’s medications. Report continues on 809 C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CAREFRONT RESIDENTIAL LIVING, LLC	FACILITY NUMBER: 079200995
	VISIT DATE: 11/06/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/27/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiency was observed during inspection:
-At approximately 1:00 PM LPA observed that the facility admitted resident (R1) with a prohibited health condition. Based on record review R1 has a Gastrostomy "g-tube" (feeding tube).
-At approximately 1:28 PM LPA observed that R2 was also admitted with a prohibited health condition. Based on record review R2 has a Gastrostomy "g-tube" (feeding tube).
-At approximately 1:35 PM LPA observed that R3 was also admitted with a prohibited heath condition.
Based on record review R3 has a Gastrostomy "g-tube" (feeding tube).
-At Approximately 1:54 PM Administrator informed LPA that R4 was also admitted with a prohibited health condition. Based on record review R4 has a Gastrostomy "g-tube" (feeding tube).
-At approximately 2:32 PM LPA observed that staff personnel records were missing forms. S1 and S2 staff files are missing LIC 501, LIC 503 and LIC 508. S3 staff file is missing LIC 503 and LIC 508

The following deficiencies were observed (see LIC 809 D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted and a copy of this report provided along with Appeal rights

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/06/2023 04:31 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CAREFRONT RESIDENTIAL LIVING, LLC	FACILITY NUMBER: 079200995
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87615(a)(2)

87615(a)(2) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above by admitting residents (R1, R2, R3 and R4) with prohibited health condition which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that residents (R1, R2, R3 and R4) have feeding tubes
	POC Due Date: 11/07/2023
	Plan of Correction
1 2 3 4	Administrator will submit an Exception Request to retain residents via email by POC date. Administrator will also separately submit a letter of explanation how the facility will care for residents while awaiting approval, to ensure residents needs are being met.

Section Cited


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

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: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/06/2023 04:31 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CAREFRONT RESIDENTIAL LIVING, LLC	FACILITY NUMBER: 079200995
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

87412(a) Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not maintaining staff records which poses/posed a potential health, safety or personal rights risk to persons in care. S1 and S2 records are missing LIC 501, LIC 503 and LIC 508. S3 record is missing LIC 503 and LIC 508
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	Administrator will obtain missing records from staff, provide proof to CCL by POC date that records have been completed and place files in staff designated folders

Section Cited


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

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: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4