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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601319
Report Date: 07/12/2023
Date Signed: 07/12/2023 03:49:47 PM

Document Has Been Signed on 07/12/2023 03:49 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:A NEW HAVEN CARE HOME - ADAMSFACILITY NUMBER:
015601319
ADMINISTRATOR:SOLETA, ARNOLD B.FACILITY TYPE:
740
ADDRESS:814 ADAMS AVENUETELEPHONE:
(925) 784-3842
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 6CENSUS: 4DATE:
07/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Arnold Soleta, Administrator/ Licensee
Robert Abella, Administrator		TIME COMPLETED:
04:00 PM
NARRATIVE
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On 7/12/2023 at 8:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Lizbeth Cruz. Administrator, Robert Abella arrived 30 minutes later, but unable to stay for the whole inspection. Administrator/Licensee, Arnold Soleta arrived towards to end of the inspection to sign the reports. The facility’s fire clearance was approved for 6 non-ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 2/9/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 116.7 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. The facility has a written emergency disaster plan.

LPA reviewed 4 resident and 4 staff files starting at 9:45AM. LPA interviewed 2 staff and 2 residents at 1:30PM. LPA reviewed a sample of resident's medications starting at 2:30PM.

At 10:00AM, LPA observed physician's report shows that R2 was bedridden and not on hospice care. LPA observed that R2 is unable to move side to side/reposition independently. Facility does not have a bedridden fire clearance.

(Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 07/12/2023 03:49 PM - It Cannot Be Edited


Created By: Grace Luk On 07/12/2023 at 02:43 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: A NEW HAVEN CARE HOME - ADAMS
FACILITY NUMBER: 015601319

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having a bedridden resident without a bedridden fire clearance which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/13/2023
Plan of Correction
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Licensee has agreed to notify the fire department and submit proof of notification, LIC200, and updated facility sketch indicating bedridden room by POC date.

Civil penalty of $500 is assessed for fire clearance 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: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/12/2023 03:49 PM - It Cannot Be Edited


Created By: Grace Luk On 07/12/2023 at 02:43 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: A NEW HAVEN CARE HOME - ADAMS
FACILITY NUMBER: 015601319

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 current annual training completed for staff which poses a potential health and safety risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Licensee has agreed to create and submit a plan to have staff complete their annual training by POC date.
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: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


LIC809 (FAS) - (06/04)
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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: A NEW HAVEN CARE HOME - ADAMS
FACILITY NUMBER: 015601319
VISIT DATE: 07/12/2023
NARRATIVE
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At 11:00AM, LPA observed staff does not have current annual training completed during record review.

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

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC809 (FAS) - (06/04)
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