<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600740
Report Date: 05/23/2022
Date Signed: 05/23/2022 11:04:32 AM

Document Has Been Signed on 05/23/2022 11:04 AM - 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:A NEW HAVEN CARE HOMEFACILITY NUMBER:
015600740
ADMINISTRATOR:ROBERT ABELLAFACILITY TYPE:
740
ADDRESS:949 DOLORES STREETTELEPHONE:
(925) 784-3842
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 6DATE:
05/23/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Robert Abella, AdministratorTIME COMPLETED:
11:20 AM
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 5/23/2022 at 9:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with Administrator, Robert Abella.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 105.8 degrees F in a resident's bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in the cabinet. Smoke and Carbon monoxide detectors observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 2/11/2022. There are no accessible bodies of water observed.

At 10:00AM, LPA observed unlocked disinfectant under the kitchen sink and unlocked knives cabinet. Staff locked up disinfectant and knives during inspection.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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 05/23/2022 11:04 AM - It Cannot Be Edited


Created By: Grace Luk On 05/23/2022 at 10:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: A NEW HAVEN CARE HOME
FACILITY NUMBER: 015600740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2022
Section Cited
CCR
87309(a)

1
2
3
4
5
6
7
Storage Space. Disinfectants, cleaning solutions,...other items which could pose a danger...shall be stored where inaccessible to clients. This requirement is not met as evidence by:
1
2
3
4
5
6
7
Staff locked up knives and disinfectant during inspection.

Deficiency cleared during inspection.
8
9
10
11
12
13
14
Based on observation, licensee did not comply with the section cited above by having unlocked disinfectant and knives which poses an immediate health and safety risk to the persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2