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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200821
Report Date: 04/04/2022
Date Signed: 04/04/2022 11:07:11 AM

Document Has Been Signed on 04/04/2022 11:07 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:LOULOU CAREFACILITY NUMBER:
079200821
ADMINISTRATOR:TCHEONG, GEOFFREYFACILITY TYPE:
740
ADDRESS:158 LEONARD DRTELEPHONE:
(925) 459-8770
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 3DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH: Geoffery Tcheong, Administrator TIME COMPLETED:
11:16 AM
NARRATIVE
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On 04/04/2022 at 9:03 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Administrator Geoffery Tcheong and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks.

The following deficiency was observed during the visit:


There is an expired fire extinguishers
There is a staff residing in resident designated room
The complaint poster not visibly posted
There is a broken light switch in bedroom one

The Facility was cited and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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 4
Document Has Been Signed on 04/04/2022 11:07 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 04/04/2022 at 10:39 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: LOULOU CARE
FACILITY NUMBER: 079200821

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

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 a light switch in bedroom one that was broken and taped up, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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The facility will fix or replace the light switch by POC date and send proof to CCLD.
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

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 a staff member residing in a room dedicated as a resident room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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The facility will either have the staff move to a staff room or reclassify the room as a staff room by POC date and send proof to CCLD.
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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/04/2022 11:07 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 04/04/2022 at 10:39 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: LOULOU CARE
FACILITY NUMBER: 079200821

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

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 the Complaint Poster posted in a place that was not visable and not in the correct size (20” x 26” in size) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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The facility will print the poster in the correct size (20” x 26” in size) and post it where it is visable to staff and residents by POC date and send proof to CCLD

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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/04/2022 11:07 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 04/04/2022 at 10:39 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: LOULOU CARE
FACILITY NUMBER: 079200821

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87212(b)(2)(A)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (2) Plan for evacuation including: (A) Fire safety plan.

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 a fire extinguishers that has not been inspected with in one year, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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The facility will have the extinguishers expected or replaced by POC date and proof will be sent to CCLD.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022


LIC809 (FAS) - (06/04)
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