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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600740
Report Date: 10/06/2022
Date Signed: 10/06/2022 10:18:45 AM

Document Has Been Signed on 10/06/2022 10:18 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: 4DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Robert Abella, AdministratorTIME COMPLETED:
10:32 AM
NARRATIVE
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On 10/6/2022 at 9:10AM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct an Infection Control Inspection. LPAs met with staff, Myrna Tolentino. Administrator, Robert Abella arrived 20 minutes later.

Upon entry, staff did not conduct COVID-19 screening for LPAs. Staff later checked LPAs' temperatures. LPAs observed hand sanitizer at screening station. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPAs observed cough etiquette, signs & symptoms, and physical distancing are posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms.

During record review, LPAs observed visitors log and temperature log for both residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. Facility staff had FIT testing for N95 respirators completed and completion certificates were reviewed. LPAs observed PPE, food supplies, and paper supplies are sufficient.

At 9:20AM, LPAs observed unlocked knives cabinet and key was on the lock. Staff locked up the knives cabinet and put away the key 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: 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 10:18 AM - It Cannot Be Edited


Created By: Grace Luk On 10/06/2022 at 09:54 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: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 key accessible on the knives cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/07/2022
Plan of Correction
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Staff removed the keys and locked up the knives cabinet during inspection.

Deficiency cleared.
Civil penalty of $250 was assessed for a repeat violation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 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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