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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200853
Report Date: 03/19/2025
Date Signed: 03/19/2025 01:49:41 PM

Document Has Been Signed on 03/19/2025 01:49 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:LIVERMORE CARE HOMEFACILITY NUMBER:
019200853
ADMINISTRATOR/
DIRECTOR:		SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:1542 PERIDOT DRTELEPHONE:
(510) 825-2383
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 5DATE:
03/19/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Wilson Censon, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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On 3/19/2025 at 12:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a POC (proof of correction) inspection. LPA met with caregiver, Wilson Censon and informed him the reason for the visit.

The following deficiencies were cleared by visit:
- 87303(e)(2); LPA measured hot water temperature at 117.2 degrees F in the hallway bathroom.
- 87309(a); LPA observed cleaning supplies and lighters were locked

Facility still has the following deficiencies that were not cleared and were issued on 3/13/2025 from California Code of Regulations, Title 22:
- 87465(h)(2); LPA observed unlocked medications in the refrigerator. Staff went out to obtain a lockbox for the medications. Staff locked up the medications in the refrigerator during POC visit. Deficiency cleared today.
- 87355(e)(2); LPA observed S4 was present at the facility and was not fingerprint cleared in the Guardian system. S4's determination status indicated as "not yet requested" as of 3/15/2024.

Civil penalties of $500 is assessed for the period of 3/15/2025 to 3/19/2025 for failure to correct for each deficiencies 87465(h)(2) and 87355(e)(2). Total civil penalties in the amount of $1000 is being assessed today. Facility is subject to ongoing civil penalties until deficiencies are corrected.

Exit interview conducted. A copy of this report, civil penalties, appeal rights, and POC letter provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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