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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201066
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:02:56 PM

Document Has Been Signed on 08/08/2024 04:02 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:GRACE HOME CARE - LLOYDFACILITY NUMBER:
019201066
ADMINISTRATOR/
DIRECTOR:		ROSARIO, GRACE DELFACILITY TYPE:
740
ADDRESS:281 LLOYD STREETTELEPHONE:
(510) 543-8013
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 3DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Luisa Tecson, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 8/8/2024 at 10:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Luisa Tecson and explained the purpose of the visit. Administrator was unable to be at the facility during inspection.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 3/28/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 105 degrees F in the hallway bathroom sink. LPA observed grab bars and non-skid mat in the resident's bathroom. First Aid kit is complete. Medications were kept locked in the cabinet located in the kitchen. Last disaster drill was conducted on 6/21/2024.

LPA reviewed 3 resident and 2 staff files starting at 11:10AM. LPA interviewed 2 residents and 1 staff starting at 2:00PM. LPA reviewed a sample of resident's medications during inspection.

At 10:30AM, LPA observed unlocked cleaning supplies in the bathrooms. LPA also observed unlocked knife and lighter in the kitchen drawer. Staff locked up the cleaning supplies, knife, and lighter during inspection.

At 1:00PM, LPA observed R3 has full bed rails and not on hospice care.

At 1:30PM, LPA observed R1 and R3 does not have a written physician's order for bed rails.

(Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 08/08/2024 04:02 PM - It Cannot Be Edited


Created By: Grace Luk On 08/08/2024 at 03:12 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: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 knife, lighter, and cleaning supplies which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Staff locked up the items 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
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Based on observation, the licensee did not comply with the section cited above by not having the correct Acetaminophen available which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Administrator has agreed to obtain Acetaminophen 325mg and submit picture proof to CCLD by POC date.

Civil penalty of $250 is being assessed for repeat violation.
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: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/08/2024 04:02 PM - It Cannot Be Edited


Created By: Grace Luk On 08/08/2024 at 03:12 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: GRACE HOME CARE - LLOYD
FACILITY NUMBER: 019201066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having written orders from a physician for R1 and R3 which poses a potential health and safety risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Facility has agreed to obtain written orders from a physician for R1 and R3's bed rails. Facility will submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by having full bed rails for R3 who is not on hospice care which poses a potential personal rights violation to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Facility has agreed to remove full bed rails for R3 and submit picture proof to CCLD by POC date.
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: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


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: 08/08/2024
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At 3:00PM, LPA observed doctor's order for R3's Acetaminophen was 325mg and take two tablets daily every 6 hours as needed. However, the bottle of Acetaminophen that was administered to R3 was Acetaminophen 500mg.

Civil penalty of $250 is being assessed for repeat violation.

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

Exit interview conducted. A copy of this report, civil penalty, and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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