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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200484
Report Date: 11/04/2024
Date Signed: 11/04/2024 05:04:20 PM

Document Has Been Signed on 11/04/2024 05:04 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:SUNOL CREEK MEMORY CAREFACILITY NUMBER:
019200484
ADMINISTRATOR/
DIRECTOR:		VENTURELLI, HARMONYFACILITY TYPE:
740
ADDRESS:5980 SUNOL BLVDTELEPHONE:
(925) 846-8283
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY: 46CENSUS: 40DATE:
11/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Harmony Venturelli, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On 11/4/2024 at 3:10PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management Inspection in regards to the incident report that was received on 10/25/2024. LPA met with Executive Director (ED), Harmony Venturelli and explained the reason for the visit.

Based on the incident report received on 10/25/2024, ED was notified that 8 residents missed their bedtime medications on 10/19/2024. Residents did not have adverse reactions due to med tech mis-communication on assisting with medications and crushing medication.

During visit, LPA reviewed incident report, MAR (Medication Administration Record), fax communication to doctors, and staff training. LPA observed S1 has medication training. Interview with staff revealed that S1 did not assist residents with the medications due to a misconception of crushed medications.


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

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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 11/04/2024 05:04 PM - It Cannot Be Edited


Created By: Grace Luk On 11/04/2024 at 04:43 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: SUNOL CREEK MEMORY CARE
FACILITY NUMBER: 019200484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2024
Section Cited
CCR
87465(c)(2)

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Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by:
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Executive Director (ED) has agreed to submit a plan to conduct medication training for S1 including hands on shadowing within two weeks.
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Based on interview and record review, licensee did not comply with the section cited above by not administering medication according to physician's order which poses an immediate health and safety risk to the persons in care.
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ED will submit written plan to CCLD by POC date.

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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: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
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