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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601501
Report Date: 06/01/2022
Date Signed: 06/01/2022 04:10:06 PM

Document Has Been Signed on 06/01/2022 04:10 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:LANDMARK VILLAFACILITY NUMBER:
015601501
ADMINISTRATOR:DIANE PEDERSONFACILITY TYPE:
740
ADDRESS:21000 MISSION BLVD.TELEPHONE:
(510) 276-2872
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 140CENSUS: 71DATE:
06/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Diane Pederson/Executive Director TIME COMPLETED:
04:00 PM
NARRATIVE
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On this day, 6/01/2022, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit. LPA met with Executive Director (ED) Diane Pederson and informed the purpose of visit.

During the course of investigation for complaint (#15-AS-20200710153037), the following deficiencies were observed:

Facility staff did not update resident’s (R1) Appraisal/Needs and Services Plan after each change in condition/hospital visit. Executive Director (ED) stated that the facility updated R1’s care plan after R1’s first fall on 11/16/2019. Staff continued to use the same updated care plan moving forward, only adjusting the need for increased safety checks and providing constant reminders to R1 to utilize her pull cord. R1’s records revealed only two (2) Appraisal/Needs and Services Plan on file dated 9/23/2019 and 11/18/2019.

It was also noted that during interview of R1’s family member (FM1) that R1 ran out of one of the medications. Facility’s records indicated they had contacted FM1 on December 2019 to pick up the medication from the pharmacy and that FM1 picked up the said medication and delivered to facility on 12/6/2019. However, when LPA requested for copies of LIC622 Centrally Stored Medication and Destruction Records on July 23, 2021 for further review, ED stated the facility no longer have the documents. On 2/07/2022, LPA verified and ED confirmed they no longer have the records.

Deficiencies are cited from Title 22 California Code of Regulations on 809D. Failure to correct deficiencies and any repeat violations within 12 month period may result in civil penalties.

Exit interview conducted. A copy of this report, Appeal Rights and LIC9098 Proof of Correction form provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2022
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 06/01/2022 04:10 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/01/2022 at 03:26 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: LANDMARK VILLA
FACILITY NUMBER: 015601501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2022
Section Cited
CCR
87463(a)

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87463 Reappraisals
(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
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R1 is no longer at the facility.

Executive Diretor to review all residents records, ensure reappraisals are updated and submit a self certification of completion by POC due date.
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-This requirement is not met as evidenced by:

-Based on interview and records review, the licensee did not comply with the section above by not updating R1's Appraisal/Needs and Services Plan which posed potential health risks to person in care.
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Type B
06/15/2022
Section Cited
CCR87506(e)

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87506 Resident Records
(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.

-This requirement is not met as evidenced by:
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R1 is no longer at the facility.

Executive Diretor to read the Regulations and by POC due date send a self-certification that residents' records will be kept for a minimum of 3 years.
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-Based on interview, the licensee did not comply with the section above for not keeping R1's records for at least 3 years which posed potential health and personal rights risks to 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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022


LIC809 (FAS) - (06/04)
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