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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200473
Report Date: 01/10/2023
Date Signed: 01/10/2023 12:37:09 PM

Document Has Been Signed on 01/10/2023 12:37 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-HUDSONFACILITY NUMBER:
019200473
ADMINISTRATOR:ARNOLD B. SOLETAFACILITY TYPE:
740
ADDRESS:1301 HUDSON WAYTELEPHONE:
(925) 784-3842
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 6DATE:
01/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Roberto Abella, AdministratorTIME COMPLETED:
12:52 PM
NARRATIVE
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On 1/10/2023 at 11:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Roberto Abella.

Upon entry, LPA's temperature was checked and asked to fill out visitor's log. 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. Hand washing posters were posted at sinks and bathrooms. Hot water was measured at 118.6 degrees F.

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

At 11:35AM, LPA observed water, juice, drinks, and some nonperishable items were stored near soaps, detergents, and cleaning supplies.

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: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023
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 01/10/2023 12:37 PM - It Cannot Be Edited


Created By: Grace Luk On 01/10/2023 at 12:15 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-HUDSON
FACILITY NUMBER: 019200473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 storing water, juice, drinks, and some nonperishable items near soaps, detergents, and cleaning supplies which poses a potential health and safety risk to persons in care.
POC Due Date: 01/17/2023
Plan of Correction
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Administrator agreed to store all drinks and nonperishable items away from soaps, detergents, and cleaning supplies. Administrator will submit picture proof to CCLD 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: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023


LIC809 (FAS) - (06/04)
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