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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200781
Report Date: 05/04/2022
Date Signed: 05/05/2022 09:22:33 AM

Document Has Been Signed on 05/05/2022 09:22 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:NEW HAVENFACILITY NUMBER:
079200781
ADMINISTRATOR:ELIZABETH CORTES- PALADFACILITY TYPE:
740
ADDRESS:2236 WHYTE PARK AVENUETELEPHONE:
(510) 965-5555
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 1DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marilou LadabanTIME COMPLETED:
05:15 PM
NARRATIVE
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On 05/04/2022 at 1:00PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with Administrator upon entry. Infection control designated leader is the administrator. Facility has a COVID-19 mitigation plan (LIC 808) in place dated 09/27/2021. LPA discussed the importance of having an updated infection control plan in accordance with PIN 22-13-ASC.

LPA inspected the facility inside and outside. LPA observed staff interacting with the client. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log. However, staff and resident were not wearing face mask, nor were and face masks or no touch thermometer at the entry point. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing.

A written Emergency/Disaster plan was posted on the bulletin board for staff, clients and visitors to read, but it is outdated. There were at least 7 days of nonperishable and 2 days of perishable foods on hand. Medications were centrally stored in a locked cabinet. Sharp objects were stored in a locked cabinet and toxic chemicals were stored in a locked cabinet inside of the garage..

Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fully functioning carbon monoxide and smoke detectors. Fire extinguishers were fully charged. All staff and client have been fully vaccinated. Adequate supplies of PPE were also observed stored on the premises. Facility follows daily cleaning and sanitation procedures on frequently touched common surfaces with disinfectants.

Continued on next page LIC 809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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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: NEW HAVEN
FACILITY NUMBER: 079200781
VISIT DATE: 05/04/2022
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/11/2022:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610D - Emergency/Disaster Plan
· LIC999 - Facility Yard Sketch with Emergency Meeting Location Added
· Evidence of Liability Insurance & Surety Bond

Facility cited with 4 Type B deficiencies.

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/05/2022 09:22 AM - It Cannot Be Edited


Created By: James Sampair On 05/04/2022 at 04:16 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: NEW HAVEN
FACILITY NUMBER: 079200781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Licensee shall improve facility Infection Control Practices with: (1) Routine symptom screening (+/- temperature and symptom check) and sign-in policy at entry for all staff, residents, and visitors. (2) Facility documenting daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents. (3) Each staff and visitor shall wear a face covering, unless an individual's exemption applies, while in the facility.
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 in the facility exterior which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2022
Plan of Correction
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Licensee shall repair fence on west side of building, west side gate, and wooden deck railing, and remove building materials and other junk in the backyard. providing proof to the LPA by the POC due 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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/05/2022 09:22 AM - It Cannot Be Edited


Created By: James Sampair On 05/04/2022 at 04:16 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: NEW HAVEN
FACILITY NUMBER: 079200781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Licensee shall replace all floor mats with non-skid mats in bathrooms and place non-skid strips or mats in all bathtubs and showers.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Licensee shall update their Emergency/Disaster Plan to the latest version: LIC610E (3/19) and then obtain and store on premises an adequate supply of water (30 gallons) and non-perishable food for 10 people for 72 hours.
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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022


LIC809 (FAS) - (06/04)
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