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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201166
Report Date: 09/07/2022
Date Signed: 09/07/2022 02:50:28 PM

Document Has Been Signed on 09/07/2022 02:50 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:FLOWERING PLUMS ASSISTED LIVINGFACILITY NUMBER:
079201166
ADMINISTRATOR:PRAMOD, KAVITHAFACILITY TYPE:
740
ADDRESS:591 FLOWERING PLUM PLTELEPHONE:
(510) 331-5774
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
09/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Kavitha Pramod, Administrator TIME COMPLETED:
03:10 PM
NARRATIVE
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On 9/7/2022 at around 10:10AM Licensing Program Analyst (LPA) L. Ibo conducted an unannounced Case Management visit regarding an incident report that was received on 9/6/2022 . LPA met with S2 and explained the reason for the visit. LPA called Administrator Kavitha Pramod and explained the purpose of the visit. Administrator arrived at the facility around 11:15AM.

The incident that was submitted for R1 occurred on 8/16/2022 where R1 was found by Police officers couple of blocks away from the facility. Based on the interview with staff, on 8/16/2022 the police officers went to the facility at around 2:30PM and informed the staff that R1 was found walking around the street. Skin tear on R1’s face was observed during the incident that prompted the Police officers call 9-1-1 and R1 was taken to the hospital.

The Physician's Report indicated that R1 has dementia and that she is unable to leave the facility unassisted. Staff interviewed indicated R1 has history of wandering behavior.

Medical records further revealed R1 had a fall with uncertain cause, based on interview with staff, R1 sustained skin tear on the left side of her face. Staff admitted that R1 did not have the skin tear while she was at the facility and was only observed when Police officers found her at the street.

Deficiency are cited from Title 22 California Code of Regulations (see 9099D). A $500.00 civil penalty is assessed. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Licensee will be called for a meeting at a later time.

Deficiency, plan and proof of correction and civil penalty were discussed with Kavitha Pramod.
Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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 3
Document Has Been Signed on 09/07/2022 02:50 PM - It Cannot Be Edited


Created By: Leslie Ibo On 09/07/2022 at 01:59 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: FLOWERING PLUMS ASSISTED LIVING
FACILITY NUMBER: 079201166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2022
Section Cited
CCR
87468.1(a)(2)

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Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe... accommodations... This requirement was not met as evidence by:

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Administrator to do the following and submit proof by 9/8/2022:

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Based on interviews and records review, the licensee did not comply with the section, facility staff failed to ensure the safety of R1; R1 was able to AWOL which posed immediate safety risk to person in care.
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 In-service all staff regarding regulation that was cited and submit copy of in-service training with attendees’ signatures.

Type A
09/08/2022
Section Cited
CCR87468.2(a)(4)

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Additional Personal Rights of Residents in Privately Operated Facilities
(a).... elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
-This requirement is not met as evidenced by:
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Civil penalty is assessed.
Administrator to conduct in-service training regarding the regulation that was cited and submit proof by POC date.

A $500.00 civil penalty is assessed.
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-Based on interviews and records review, the licensee did not comply with the section above. R1 was able to AWOL unnoticed. R1 was found by Police officers couple of blocks away from the facility, R1 sustained skin tear while away from the facility. These posed immediate safety and personal rights and safety risks to person in care.
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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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/07/2022 02:50 PM - It Cannot Be Edited


Created By: Leslie Ibo On 09/07/2022 at 02:39 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: FLOWERING PLUMS ASSISTED LIVING
FACILITY NUMBER: 079201166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2022
Section Cited
CCR
87705(j)

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Care of Persons with dementia:
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
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Licensee shall have fucntional auditory device/alert feature placed on each exit door at facility.

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Based on observation, licensee failed to ensure that an auditory device or other staff alert feature to monitor exits is placed on exit doors, which poses a potential risk to the health and safety of residents in care.
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In-service all staff regarding teh regulation that was cited and submit copy of in-service training with attendees’ signatures.

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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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022


LIC809 (FAS) - (06/04)
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