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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200995
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:56:47 PM

Document Has Been Signed on 10/15/2024 02:56 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:CAREFRONT RESIDENTIAL LIVING, LLCFACILITY NUMBER:
079200995
ADMINISTRATOR/
DIRECTOR:		WANG, DINGFACILITY TYPE:
740
ADDRESS:4086 TULARE DRTELEPHONE:
(925) 890-8953
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 6DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Ma Sinelita Rivera, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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On 10/15/2024 at 9:45am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year required inspection. LPA met with Ma Sinelita Rivera, Caregiver, and explained the purpose of the visit. LPA spoke with Ding Wang, Administrator via telephone and received approval for caregiver to sign documents. The facility’s fire clearance was approved for five (5) non-ambulatory, and one (1) bedridden resident. Facility has a hospice waiver for two (2).

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of eight (8) bedrooms and two (2) bathrooms. One (1) bedroom in the house and one (1) in the garage is occupied by staff. LPA did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 99.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide had beeping low battery sound. First aid kit was observed to be complete.

Continued on LIC809.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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: CAREFRONT RESIDENTIAL LIVING, LLC
FACILITY NUMBER: 079200995
VISIT DATE: 10/15/2024
NARRATIVE
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Continued from LIC809.

LPA reviewed three (3) staff files and none had first aid or CPR. All six (6) residents' files were reviewed and missing documents.

LPA observed the following deficiencies:
  • At 10:15am, LPA observed during record review R1, R2, and R3 does not have an exception for prohibited health condition.
  • At 10:30am, LPA observed during record review that none of the residents have an appraisal needs and services plan.
  • At 10:30am, LPA observed during record review R4 and R5 did not have a hospice care plan.
  • At 10:30am, R1, R2, and R3 does not have a doctor's order for hospital bed with full rails.
  • At 10:45am, LPA observed during record review Administrator's file was not available for review.
  • At 10:45am, LPA observed the three (3) staff files reviewed did not have first aid or CPR.
  • At 11:00am, LPA observed unlocked kitchen cabinet over dishwasher containing knives.
  • At 11:05am, LPA observed R5's bed blocking patio exit in room #3, but on facility sketch it shows (#4).
  • At 11:15am, LPA observed alterations completed at facility. Garage has a bedroom, bedroom added on side of living room (1), small staff room added behind laundry room and room #1 on facility sketch.
  • At 11:20am, LPA observed facility did not complete a fire drill.
  • At 11:25am, LPA observed fire extinguisher has not be repurchased or serviced.


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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: CAREFRONT RESIDENTIAL LIVING, LLC
FACILITY NUMBER: 079200995
VISIT DATE: 10/15/2024
NARRATIVE
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Continued from LIC809C.
  • At 11:30am, LPA observed 6 hoyer lifts, a rolling tray, a hospital bed, and a wheelchair in the back yard.
  • At 11:30am, LPA observed shed located in the back yard unlocked.


LPA requested the following documents to be submitted to CCLD by 10/22/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (9 pages)
  • Liability insurance

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate civil penalty of $250.00 for a repeat violation will be assessed on today's date*

Exit interview conducted. A copy of appeal rights, LIC421FC, and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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Page: 3 of 10
Document Has Been Signed on 10/15/2024 02:56 PM - It Cannot Be Edited


Created By: Laura Hall On 10/15/2024 at 01:22 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: CAREFRONT RESIDENTIAL LIVING, LLC
FACILITY NUMBER: 079200995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having knives in kitchen unlocked kitchen cabinet and shed in back yard unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2024
Plan of Correction
1
2
3
4
Administrator agreed to lock shed and make knives inaccessible to residents and submit photos to CCLD by POC date.
Type A
Section Cited
CCR
87615(a)(2)
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:

(2) Gastrostomy tubes.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having an approved exception for R1, R2, and R3 prohibited health condition which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2024
Plan of Correction
1
2
3
4
Administrator agreed to submit exception request for R1, R2, and R3 prohibited health condition 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


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Document Has Been Signed on 10/15/2024 02:56 PM - It Cannot Be Edited


Created By: Laura Hall On 10/15/2024 at 01:22 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: CAREFRONT RESIDENTIAL LIVING, LLC
FACILITY NUMBER: 079200995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having any of the staff first aid or CPR certified which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
1
2
3
4
Administrator agreed to have all staff first aid certified and at least one staff per shift CPR certified. Certificates will be submitted to CCLD by POC date.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) 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, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having appraisal needs and services plan for each resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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2
3
4
Administrator agreed to fully fill out an appraisal needs and services plan for each resident and submit 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 10/15/2024 02:56 PM - It Cannot Be Edited


Created By: Laura Hall On 10/15/2024 at 01:22 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: CAREFRONT RESIDENTIAL LIVING, LLC
FACILITY NUMBER: 079200995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having doctor's orders for R1, R2, and R3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
1
2
3
4
Administrator agreed to obtain a doctor's order for full bed rail for R1, R2, and R3 and submit order to CCLD by POC date.
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having a hospice care plan at facility for R4 and R5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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2
3
4
Administrator agreed to obtain a hospice care plan for R4 and R5 and submit it 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 10/15/2024 02:56 PM - It Cannot Be Edited


Created By: Laura Hall On 10/15/2024 at 01:55 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: CAREFRONT RESIDENTIAL LIVING, LLC
FACILITY NUMBER: 079200995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in not having administrator file available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
1
2
3
4
Administrator agreed to read regulation 87412, and submit self-certification that it has been read and agree to abide by regulation going forward to CCLD by POC date.
Type B
Section Cited
CCR
87705(k)(3)
(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates:

(3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in conducting a fire drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
1
2
3
4
Administrator agreed to conduct a fire drill and fully complete document and submit 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2024 02:56 PM - It Cannot Be Edited


Created By: Laura Hall On 10/15/2024 at 02:00 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: CAREFRONT RESIDENTIAL LIVING, LLC
FACILITY NUMBER: 079200995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in obtaining a building permit or contacting CCLD prior to construction which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
1
2
3
4
Administrator agreed to submit an LIC200 and updated facility sketch to CCLD by POC date.
Type B
Section Cited
CCR
87203
(c) All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having the fire extinguisher serviced or purchased, and changing the battery in the smoke detector which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
1
2
3
4
Administrator agreed to have fire extinguishers serviced or purchase new ones and change battery or have smoke detector services. Also, to submit photos 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 10/15/2024 02:56 PM - It Cannot Be Edited


Created By: Laura Hall On 10/15/2024 at 02:10 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: CAREFRONT RESIDENTIAL LIVING, LLC
FACILITY NUMBER: 079200995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
(d) The following space and safety provisions shall apply to all facilities:

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having hoyer lifts, tray, wheelchair, and bed frame in back yard. Also R5 is blocking emergency exit in bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
1
2
3
4
Administrator agreed to have items removed from back yard, change R5's position not to block exit, and submit photos to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 10/15/2024 02:56 PM - It Cannot Be Edited


Created By: Laura Hall On 10/15/2024 at 02:16 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: CAREFRONT RESIDENTIAL LIVING, LLC
FACILITY NUMBER: 079200995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:

(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having R1's medication locked in refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2024
Plan of Correction
1
2
3
4
Administrator agreed to have medication made in accessible to residents and submit photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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