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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601428
Report Date: 09/16/2022
Date Signed: 09/16/2022 10:26:37 AM

Document Has Been Signed on 09/16/2022 10:26 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 HOME - HAMPTONFACILITY NUMBER:
015601428
ADMINISTRATOR:SOLETA, ARNOLD B.FACILITY TYPE:
740
ADDRESS:1356 HAMPTON PLACETELEPHONE:
(925) 784-3842
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 5DATE:
09/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nenita Manuel, CaregiverTIME COMPLETED:
10:40 AM
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On 9/16/2022 at 9:00AM, Licensing Program Analysts (LPAs) G. Luk and P. Watson arrived unannounced to conduct a Case Management visit in regards to death report received on 9/9/2022. LPAs met with caregiver, Nenita Manuel. LPAs spoke with Administrator, Arnold Soleta over the phone and was unable to be at the facility.

LPAs received death report on 9/9/2022 for resident (R1). Death report stated that resident was found unresponsive and staff called 911. Paramedics arrived and pronounced death.

LPAs interviewed staff who stated that R1 was on palliative care. On 9/9/2022, staff (S1) went into R1's room at around 7AM and cover R1 with blanket. S1 stated R1 was sleeping and didn't want to wake R1 up at 7AM. When S1 tried to wake R1 up at around 8:50AM, R1 was unresponsive and called 911. Record review showed that R1 had a diagnosis of renal failure and was on dialysis for 8 years. R1 had a DNR.

While LPAs was at the facility reviewing information regarding the death report, R2 was upset and had a behavior. LPAs have staff called R2's family member and confirmed that R2 recently moved to the facility. R2 is still adjusting to living at the facility. LPAs advise administrator to following up with R2's family and doctor regarding R2.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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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