079201027-10-6-2022-15-AS-LFRO-CJXRFF-20221006125903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201027
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:59:26 PM

Document Has Been Signed on 10/06/2022 12:59 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:	NAVAJO CARE HOME		FACILITY NUMBER:	079201027
ADMINISTRATOR:	CHAUDHRY, TAYYABA		FACILITY TYPE:	740
ADDRESS:	3 NAVAJO COURT		TELEPHONE:	(925) 433-6000
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	6	CENSUS: 4	DATE:	10/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Jaidi Smith, Back-up Administrator		TIME COMPLETED:	12:15 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 10/6/2022 starting at 10:55 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPAs were greeted by care staff, Gilbert David and LPAs explained the purpose of the visit. Back-up Administrator, Jaidi Smith later arrived at 11:30 AM. During the Infection Control Inspection, LPAs toured facility with Back-up Administrator including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a minimum 30-day supply of PPEs maintained at central location and easily accessible for staff. At 12:10 PM, LPAs reviewed a sample of 2 staff records and 2 of 2 staff have TB test results on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff. REPORT CONTINUES ON 809C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/06/2022 12:59 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: NAVAJO CARE HOME	FACILITY NUMBER: 079201027
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

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, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 by storing rubbing alochol and DayQuil in unlocked cabinet which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/07/2022
	Plan of Correction
1 2 3 4	Deficiency cleared during visit. LPAs observed staff removed items and locked it away. In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signatures to CCL by 10/17/22.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC809 (FAS) - (06/04)

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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: NAVAJO CARE HOME	FACILITY NUMBER: 079201027
	VISIT DATE: 10/06/2022

NARRATIVE

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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 11:05 AM during record review, LPAs observed S1 is fingerprint cleared. However, S1 is not associated to the facility
At 11:45 AM, LPAs observed rubbing alcohol and DayQuil being stored in an unlocked kitchen cabinet. Deficiency cleared during visit, LPAs observed care staff removed items and locked it away.
At 11:55 AM during record review, LPAs observed S1 and S2 does not have a complete health screening on file signed by a physician.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/14/2022:

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

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC809 (FAS) - (06/04)

Page: 7 of 8

Document Has Been Signed on 10/06/2022 12:59 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: NAVAJO CARE HOME	FACILITY NUMBER: 079201027
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(2)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 associating S1 to the facility which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/10/2022
	Plan of Correction
1 2 3 4	By POC date, Administrator will associate S1 to the facility's roster and submit a proof of association to CCLD.

Type B

Section Cited

CCR

87411(f)

87411(f) Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening….. 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 completing the health screening (LIC 503) by a physician for S1 and S2 which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	By POC date, Administrator will obtain a complete health screening signed by a physician for S1 and S2, and submit a copy to CCLD.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC809 (FAS) - (06/04)

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