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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200821
Report Date: 03/27/2023
Date Signed: 03/27/2023 01:19:36 PM

Document Has Been Signed on 03/27/2023 01:19 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:LOULOU CAREFACILITY NUMBER:
079200821
ADMINISTRATOR:TCHEONG, GEOFFREYFACILITY TYPE:
740
ADDRESS:158 LEONARD DRTELEPHONE:
(925) 459-8770
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 4DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Geoffrey Tcheong, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 03/27/2023 at 9:50 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Caregiver Anelie Sagoinit and explained the purpose of the visit. Administrator Geoffrey Tcheong joined later.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan.

At 12:02 pm LPA reviewed 4 residents records. At 12:45 PM, LPA reviewed 3 staff records and 5 of 5 were fingerprint cleared and associated to the facility.

Continued on LIC 809C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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 03/27/2023 01:19 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 03/27/2023 at 11:57 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

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 lights not functioning on multiple rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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The facility will go through each bedroom and evauate the lighting then, fix or replace the lighting as needed. Proof of correction will be sent to CCLD by POC date
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 by having one staff record not present at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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The facility will update the staff records binder to include the new staff members and remove the previous staff who no longer work at the facility. Proof of correction will be sent 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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/27/2023 01:19 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 03/27/2023 at 11:57 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

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 by not providing to required training to the staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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The facility will create a monthly training calendar for the staff. Proof of correction will be sent to CCLD by POC date
Type B
Section Cited
HSC
1569.696(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

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 by not providing to required training to the staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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The facility will create a monthly training calendar for the staff. Proof of correction will be sent 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:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/27/2023 01:19 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 03/27/2023 at 11:57 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

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 in above by not providing to required training to the staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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3
4
The facility will create a monthly training calendar for the staff. Proof of correction will be sent to CCLD by POC date
Section Cited
Deficient Practice Statement
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4
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: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


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: LOULOU CARE
FACILITY NUMBER: 079200821
VISIT DATE: 03/27/2023
NARRATIVE
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...Continued from LIC809

The following deficiency was observed during the visit:
Lighting in a few of the rooms was not working
Two staff records were not at the facility
Staff training logs were not up to date
Staff training on postural support
Staff training on care and supervision

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: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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