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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201066
Report Date: 07/13/2022
Date Signed: 07/13/2022 11:59:38 AM

Document Has Been Signed on 07/13/2022 11:59 AM - 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:GRACE HOME CARE - LLOYDFACILITY NUMBER:
019201066
ADMINISTRATOR:ROSARIO, GRACE DELFACILITY TYPE:
740
ADDRESS:281 LLOYD STREETTELEPHONE:
(510) 543-8013
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 4DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Janet Quines, AdministratorTIME COMPLETED:
12:10 PM
NARRATIVE
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On 7/13/2022 at 8:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Janet Quines.

Upon entry, staff did not conduct COVID-19 screening for LPA. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, garage, 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.

During record review, LPA observed visitors log. LPA observed facility has a copy of Mitigation Plan on file. Fit testing for N95 respirator was completed and completion certificate reviewed. LPA observed PPE, food supplies, and paper supplies are sufficient.

At 9:10AM, LPA observed unlocked cleaning supplies in staff bathroom and garage. Lock for knives drawer was broken. There were unlocked scissors in kitchen and backyard. Staff put a lock on the cabinet in the staff bathroom.

At 9:20AM, LPA observed unlocked medication in the refrigerator and lockbox was unlocked. Also, medication cabinet was unlocked. Staff locked up medication cabinet and lockbox during inspection.

At 9:30AM, LPA observed store purchased eggs were left out on the kitchen counter top and was informed it was been there for about 2 days. LPA informed staff that store purchased eggs needs to be refrigerated. Staff threw out the eggs during inspection.
(Continue on LIC9099C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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 07/13/2022 11:59 AM - It Cannot Be Edited


Created By: Grace Luk On 07/13/2022 at 11:09 AM
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: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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
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Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies and broken lock for the knives drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/14/2022
Plan of Correction
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Staff locked up cleaning supplies and scissors. Staff will fix the lock and send picture proof to CCLD by POC date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 having unlocked medication in the refrigerator and unlocked medication cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/14/2022
Plan of Correction
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Staff locked up the medication in the refrigerator and the medication cabinet during inspection.

Deficiency cleared.
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: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2022 11:59 AM - It Cannot Be Edited


Created By: Grace Luk On 07/13/2022 at 11:09 AM
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: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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Based on observation, the licensee did not comply with the section cited above by having clutter in the backyard on the passageway which poses a potential health and safety risk to persons in care.
POC Due Date: 07/20/2022
Plan of Correction
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Staff removed clutter from backyard passageways during inspection.

Deficiency cleared.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

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 pre-refrigerated eggs on counter top at room temperature for a couple days which poses a potential health and safety risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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LPA witnessed staff threw away contaminated eggs in the garbage can during inspection.

Deficiency cleared.
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: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066
VISIT DATE: 07/13/2022
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At 9:40AM, LPA observed passageway in the backyard has lots of clutter including bikes, boxes, and other items. Staff removed the clutter during inspection.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies 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: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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