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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201082
Report Date: 01/03/2025
Date Signed: 01/03/2025 05:50:52 PM

Document Has Been Signed on 01/03/2025 05:50 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 - MEADOWLARKFACILITY NUMBER:
019201082
ADMINISTRATOR/
DIRECTOR:		DEL ROSARIO, GRACEFACILITY TYPE:
740
ADDRESS:538 MEADOWLARK STREETTELEPHONE:
(510) 543-8013
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 6CENSUS: 5DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Amalia Saptang, CaregiverTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 1/3/2025 at 10:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Caregiver, Amalia Saptang and explained the purpose of the visit.

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 extinguisher was 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 119.7 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. First Aid kit is complete. LPA reviewed 5 residents and 3 staff files starting at 11:10AM. LPA reviewed a sample of resident's medications. LPA interviewed 2 residents and 1 staff during inspection.

At 12:00PM, LPA observed residents does not have current needs and service plans.

At 1:45PM, LPA observed side gate latch was broken, side fence that meets the side gate was leaning towards the neighbor's property, and there were mattresses and beds stored openly in the back yard.

At 4:45PM, LPA observed R2's medical assessment dated 2/28/2024 stated that R2 is unable to administer own injections and unable to perform own glucose testing. R2 has current doctor's order for insulin. However, R2 currently does not have home health nurse to assist with insulin and facility does not have nurse on staff.

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: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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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Document Has Been Signed on 01/03/2025 05:50 PM - It Cannot Be Edited


Created By: Grace Luk On 01/03/2025 at 05:11 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 - MEADOWLARK
FACILITY NUMBER: 019201082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(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
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Based on record review, the licensee did not comply with the section cited above by not having current needs and service plans for residents which poses a potential health and safety risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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Facility has agreed to go over the needs and service plans with residents and/or responsible party. Facility will submit the plans with signatures 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: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/03/2025 05:50 PM - It Cannot Be Edited


Created By: Grace Luk On 01/03/2025 at 05:31 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 - MEADOWLARK
FACILITY NUMBER: 019201082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(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
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Based on observation, the licensee did not comply with the section cited above by having broken gate latch, leaning fence, and mattresses & bed frames stored in the backyard which poses a potential health and safety risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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Facility has agreed to create a plan to address these items that are broken or left in the backyard. Facility will submit the plan to CCLD by POC date.
Type B
Section Cited
CCR
87628(a)
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not having a skilled professional to assist resident with glucose testing and injections which poses a potential health and safety risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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Facility has agreed to create a plan to address the current issue of resident not able to perform own glucose testing and administer own injection. Facility will submit the plan 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: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
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