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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201173
Report Date:
06/30/2023
Date Signed:
06/30/2023 02:04:01 PM
Document Has Been Signed on
06/30/2023 02:04 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:
BUTTERCUP AT OAK GROVE
FACILITY NUMBER:
079201173
ADMINISTRATOR:
WARD, WHITNEY
FACILITY TYPE:
740
ADDRESS:
993 OAK GROVE ROAD
TELEPHONE:
(415) 710-5169
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94518
CAPACITY:
6
CENSUS:
3
DATE:
06/30/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:25 AM
MET WITH:
Paul Mellander
TIME COMPLETED:
02:15 PM
NARRATIVE
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On 06/30/2023 at 09:25 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with staff Paul Mellander and explained the purpose of the visit. Licensee Matt Ward was called and was unable to make it to the facility for the visit and designated Paul to sign off on the report.
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. 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. Cabinet for knives waere observed with locks. 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 05/03/2023.
At 10:02 am LPA reviewed 3 residents records. At 11:05 am, LPA reviewed 6 staff records and 6 of 6 were fingerprint cleared and associated to the facility.
The following T.A. was observed during the visit:
A home health nurse (not facility staff) was given the key to the laundry/chemical storage room and left it unlocked
Continued on LIC 809C...
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
06/30/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
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Document Has Been Signed on
06/30/2023 02:04 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:
BUTTERCUP AT OAK GROVE
FACILITY NUMBER:
079201173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/30/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)
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:
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 complete records of all staff at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/07/2023
Plan of Correction
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The facility agrees to collect and create complete staff records for each staff member at the facility. These records will include LIS 501, 503, 508, 9052, and transfer request forms. Proof of correction will be sent to CCLD by POC date.
Type A
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.
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 having bottles of soap stored in the same cabinets with food next to the kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/03/2023
Plan of Correction
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The facility will move the soap to a diffrent location not stored with food. Proof of correction will be sent to CCLD by POC date.
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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
06/30/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2023
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
06/30/2023 02:04 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:
BUTTERCUP AT OAK GROVE
FACILITY NUMBER:
079201173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/30/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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 having the medication cabinet unlocked and open for an hour which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/30/2023
Plan of Correction
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Correction was made durring visit. The facility locked the medication storage.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
06/30/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2023
LIC809
(FAS) - (06/04)
Page:
3
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Document Has Been Signed on
06/30/2023 02:04 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:
BUTTERCUP AT OAK GROVE
FACILITY NUMBER:
079201173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/30/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87113
Posting of License
The license shall be posted in a prominent location in the licensed facility accessible to public view.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above because the facility license was found in a binder labled "Resident File." which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/07/2023
Plan of Correction
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The facility agrees to post the licnese in a space that can be viewed by the public such as a hallway or living space. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above for having old furniture left in the backyard, and for having a part of the flooring missing in bedroom 4's closet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/14/2023
Plan of Correction
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The facility agrees to fix or replace the floor in bedroom 4's closet, and the facility agrees to have the broken/un-used furniture removed from the backyard. Proof of correction will be sent to CCLD by POC date.
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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
06/30/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2023
LIC809
(FAS) - (06/04)
Page:
4
of
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Document Has Been Signed on
06/30/2023 02:04 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:
BUTTERCUP AT OAK GROVE
FACILITY NUMBER:
079201173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/30/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(A)
Personal Accommodations and Services
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by not having a bed in room 5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/14/2023
Plan of Correction
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The facility agrees to put a bed into room 5. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not being at the facility and keeping up with the facility record for enough hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/14/2023
Plan of Correction
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The facility will submit the LIC 500 showing the staff and administrator schedule to CCLD. Proof of correction will be sent to CCLD by POC date.
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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
06/30/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2023
LIC809
(FAS) - (06/04)
Page:
5
of
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Document Has Been Signed on
06/30/2023 02:04 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:
BUTTERCUP AT OAK GROVE
FACILITY NUMBER:
079201173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/30/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above by having incomplete resident records for each resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/21/2023
Plan of Correction
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The facility agrees to go through each resident record and ensure that they have the admissions agreement, pre-appraisal, needs and services plan, physicians report, personal rights, and property/valuables that are all signed dated and easily assessable. Proof of correction will be sent to CCLD by POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
06/30/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2023
LIC809
(FAS) - (06/04)
Page:
6
of
9
Document Has Been Signed on
06/30/2023 02:04 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:
BUTTERCUP AT OAK GROVE
FACILITY NUMBER:
079201173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/30/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
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 not having the PUB 475 in the size 20” x 26” which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/21/2023
Plan of Correction
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2
3
4
The facility agrees to get a copy of the poster printed to the correct 20” x 26” size and post it in the facility. Proof of correction will be sent to CCLD by POC date.
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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
06/30/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2023
LIC809
(FAS) - (06/04)
Page:
7
of
9
Document Has Been Signed on
06/30/2023 02:04 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:
BUTTERCUP AT OAK GROVE
FACILITY NUMBER:
079201173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/30/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
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 having the kitchen counters over filled to the point that food and beverages are being stored on the floor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/14/2023
Plan of Correction
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2
3
4
The facility will clean off the counter and re-evaulate the the kitchen storage areas. Proof of correction will be sent to CCLD by POC date.
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:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
06/30/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2023
LIC809
(FAS) - (06/04)
Page:
8
of
9
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:
BUTTERCUP AT OAK GROVE
FACILITY NUMBER:
079201173
VISIT DATE:
06/30/2023
NARRATIVE
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...Continued from 809
The following deficiency was observed during the visit:
The facility did not have complete staff records
the facility had soap being stored with food in the upper cabinets by the kitchen sink
The medication cabinet was observed unlocked for over an hour
The facilities License is not posted
There is old and broken furniture left outside/ flooring is missing in room 4's closet
There is no bed in room 5
The administrator is not at the facility for a sufficient number of hours
The resident records are disorganized and incomplete
The facility does not have PUB 475 in the correct size of 20 X 26"
The counters in the kitchen are full and food/beverages are being stored on the floor
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. Exit interview conducted.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2023
LIC809
(FAS) - (06/04)
Page:
9
of
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