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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600740
Report Date: 09/21/2022
Date Signed: 09/21/2022 11:46:07 AM

Document Has Been Signed on 09/21/2022 11:46 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: 5DATE:
09/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Arnold Soleta, Licensee
Roberto Abella, Administrator		TIME COMPLETED:
11:55 AM
NARRATIVE
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On 9/21/2022 at 10:30AM, Licensing Program Analysts (LPAs) G. Luk and M. Malik arrived unannounced to conduct a case management visit. LPA met with Administrator, Roberto Abella. Licensee, Arnold Soleta arrived 30 minutes later.

While LPAs was at the facility conducting another visit, LPAs observed the following deficiencies.

- During the Department investigation regarding complaint #15-AS-20220517085029, it was identified that facility did not report R2's death to CCLD.

- It was also identify that S1 was not associated to the facility. LPAs reviewed Guardian and observed S1 was fingerprint cleared and not associated to the facility.

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

Exit interview conducted with Arnold. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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 09/21/2022 11:46 AM - It Cannot Be Edited


Created By: Grace Luk On 09/21/2022 at 11:01 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: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2022
Section Cited
CCR
87211(a)(1)(A)

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Reporting Requirements. A written report shall be submitted to the licensing agency...Death of any resident...
This requirement is not met as evidence by:
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Administrator has agreed to review and re-train all staff regarding reporting requirements. Facility will submit staff sign in sheet and training materials to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not submitting death reports for R2 which poses a potential health and safety risk to the person in care.
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Type B
09/28/2022
Section Cited
CCR87355(e)(2)

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Criminal Record Clearance. All individuals subject to a criminal record review...Request a transfer of a criminal record clearance...
This requirement is not met as evidence by:
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Administrator has agreed to associate S1 and provide document to CCLD by POC date.
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Based on investigation, 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 the person in care.
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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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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