Community Care Licensing

Document Has Been Signed on 03/26/2024 03:08 PM - It Cannot Be Edited

FACILITY NAME:	LIVERMORE CARE HOME		FACILITY NUMBER:	019200853
ADMINISTRATOR:	SANDHU, SEEMA		FACILITY TYPE:	740
ADDRESS:	1542 PERIDOT DR		TELEPHONE:	(510) 825-2383
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY: 6		CENSUS: 4	DATE:	03/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Wilson Censon, Caregiver		TIME COMPLETED:	03:25 PM

SUPERVISORS NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Grace Luk LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

FACILITY NAME: LIVERMORE CARE HOME	FACILITY NUMBER: 019200853
	VISIT DATE: 03/26/2024

Link to Parent Document Below:

FACILITY NAME: LIVERMORE CARE HOME	FACILITY NUMBER: 019200853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked knives, tools, cleaning supplies, and lighters at the facility which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/27/2024
	Plan of Correction
1 2 3 4	Staff locked up the knives, tools, cleaning supplies, and lighters during inspection. Deficiency cleared.

Type A

Section Cited

CCR

87465(c)(2)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not following doctor's order when giving R1's medication which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/27/2024
	Plan of Correction
1 2 3 4	Facility has agreed to conduct training for staff on medication administration and completing the MAR. Facility will submit training log to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Grace Luk LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Link to Parent Document Below:

FACILITY NAME: LIVERMORE CARE HOME	FACILITY NUMBER: 019200853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having room 4's screen door in disrepair and dog feces in backyard which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Facility has agreed to repair screen door in room 4 and clean up the dog feces in the backyard. Facility will submit picture proof to CCLD by POC date.

Type B

Section Cited

HSC

1569.625(b)(2)

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having current annual training for staff which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Facility has agreed to obtain annual training for S2 and S3 and submit training documents to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Grace Luk LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Link to Parent Document Below:

FACILITY NAME: LIVERMORE CARE HOME	FACILITY NUMBER: 019200853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type B

Section Cited

HSC

1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having initial training for staff which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Facility has agreed to obtain initial training for S2 and S3 and submit documents of training to CCLD by POC date.

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not TB test results for R3 and R4 which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Facility has agreed to obtain TB test results for R3 and R4 and submit copies of documentation to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Grace Luk LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Link to Parent Document Below:

FACILITY NAME: LIVERMORE CARE HOME	FACILITY NUMBER: 019200853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type B

Section Cited

CCR

87467(a)(3)

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having current needs and service plans for three residents which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Facility has agreed to obtain current needs and service plan for R1, R2, and R3, and submit copies to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Grace Luk LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024

Link to Parent Document Below:

FACILITY NAME: LIVERMORE CARE HOME	FACILITY NUMBER: 019200853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

Type B

Section Cited

CCR

87411(c)(1)

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having current first aid training for staff which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Facility has agreed to obtain current first aid training for S2 and S3 and submit copies of completion to CCLD by POC date.

Type B

Section Cited

CCR

87468.2(a)

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having baby monitors in resident's rooms which poses a potential personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Facility has agreed submit a written plan to install a signal system in place of the baby monitors. Facility will submit plans to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal LICENSING EVALUATOR NAME: Grace Luk LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024