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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601187
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:04:54 PM

Document Has Been Signed on 03/10/2022 04:04 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:HRS CARE HOMEFACILITY NUMBER:
015601187
ADMINISTRATOR:DE LUNA, DIOSDADOFACILITY TYPE:
740
ADDRESS:1352 ASTER LANETELEPHONE:
(925) 454-3320
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 6DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Diosdado De Luna, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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On 3/10/2022 at 1:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Diosdado De Luna.

Upon entry, staff did not screen LPA prior to entry. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPA 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.

During record review, LPA observed visitors log. LPA observed facility has a copy of Mitigation Plan on file. LPA observed food supplies and paper supplies are sufficient.

At 1:50PM, LPA observed unlocked cleaning supply under the kitchen sink. Staff locked up cleaning supply during inspection.

At 2:00PM, LPA observed unlocked medications on the dining table, hallway closet, and medication cabinet/drawers. Staff locked up the medications during inspection.

At 3:00PM, LPA observed two staff did not have TB test results on file during record review.

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. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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 9
Document Has Been Signed on 03/10/2022 04:04 PM - It Cannot Be Edited


Created By: Grace Luk On 03/10/2022 at 03:21 PM
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: HRS CARE HOME
FACILITY NUMBER: 015601187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022

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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4
Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies under the sink which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Staff lock up the cleaning supplies during inspection.

Deficiency cleared during inspection.
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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4
Based on observation, the licensee did not comply with the section cited above by having unlocked medications on dining table and in hallway closet which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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2
3
4
Staff locked up medications during inspection.

Deficiency cleared during inspection.
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: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 03/10/2022 04:04 PM - It Cannot Be Edited


Created By: Grace Luk On 03/10/2022 at 03:21 PM
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: HRS CARE HOME
FACILITY NUMBER: 015601187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
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, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 TB test results which poses a potential health and safety risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
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Administrator will submit TB test results for the two staff 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
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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