Carefield Pleasanton

Type of visit: Required - 1 Year

On 8/17/2026 at 9:30AM, Licensing Program Analysts (LPA) A. Gomez arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Executive Director, Eunice O'Farrell and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity room, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication carts. First Aid kit is complete. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 1/22/2026. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food supplies twice a week. Freezer’s temperature was registered at -1 degree F while the refrigerator’s temperature was recorded at 39 degrees F. Grab bars and non-skid mat/materials were observed in residents showers. No bodies of water observed. LPA reviewed 5 residents and 5 staff files. LPA reviewed a sample of resident's medications during inspection. Hot water measured between 105.0 and 120.0 degrees F in a sample of resident's bathrooms. Emergency Disaster Plan was last posted on 8/25/2025. Emergency disaster drill was last conducted on 8/7/2026. Updated copies of the following documents were requested for facility file and are to be mailed to CCL by 9/1/2026: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 17, 2026

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 8/12/2025 at 9:45AM, Licensing Program Analysts (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Executive Director, Eunice O'Farrell and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity room, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 1/13/2025. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food supplies twice a week. Freezer’s temperature was registered at -1 degree F while the refrigerator’s temperature was recorded at 39 degrees F. Grab bars and non-skid mat/materials were observed. LPA reviewed 5 residents and 6 staff files starting at 11:10AM. LPA reviewed a sample of resident's medications during inspection. At 10:20AM, LPA measured hot water at 130.4 degrees F in a resident's bathroom. Staff lowered hot water and LPA re-measured hot water at 111.4 degrees F in the same bathroom. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 12, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 1/24/2025 at 12:50PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 1/20/2025. LPA met with Executive Director, Eunice O'Farrell and explained the purpose of the visit. Death report revealed that R1 was found unresponsive by staff and 911 was called. R1 passed away at the hospital on 1/15/2025 with cause of death unknown. LPA interviewed staff and reviewed documents including R1's physician's report, care plan, and facility notes. On 1/15/2025, staff found R1 looking pale and unresponsive while in bed. R1's physician's report revealed that R1 had long standing persistent fibrillation. Staff called 911 and R1 was transported to the hospital. Family notified facility staff that R1 passed away later that day at the hospital. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jan 24, 2025

Type of visit: Case Management - Incident

On 1/24/2025 at 2:25PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 1/23/2025. LPA met with Executive Director, Eunice O'Farrell and informed her the reason for the visit. Based on the incident report received on 1/23/2025, med tech noticed that R1 was not in his room and was not able to be located during safety status check around 7:20PM on 1/16/2025. The door located in the back parking lot was left propped open while a vendor was bringing in their equipment. Police department was notified and R1 was located by police. R1 was transported back to the facility by R1's family/POA. During visit, LPA interviewed staff and reviewed R1's file including physician's report, service plan, care notes, and incident report. R1's physician's report stated that R1 cannot leave the facility unassisted. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(7) · Plan of correction due date: Feb 7, 2025

Care of Persons with Dementia. Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents... This requirement is not met as evidence by: Based on interview and record review, licensee did not comply with the section cited above by having a resident leaving the facility unassisted which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: Executive Director (ED) has agreed to create a plan to address situations when exit door is propped open. ED will submit a copy of the plan to CCLD by POC date.

Allegation investigated: Facility not allowing family members to visit resident. Facility not allowing resident to receive phone calls.

On 8/27/2024 at 3:30PM, Licensing Program Analysts (LPAs) G. Luk and P. Manalo arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegations above. LPAs met with Executive Director, Eunice O'Farrell and explained to her the reason for the visit. During the investigation, LPA G. Luk interviewed 3 residents, 2 staff, and complainant. LPAs reviewed and obtained documents including staff roster with contact information, physician's report, emergency information, POA documents, email correspondence, visitation records, and phone call records Facility not allowing family members to visit resident. Interview with residents revealed that family members does visit residents at the facility. After reviewing resident visitor logs, LPAs observed that residents are receiving visitors. Interview with staff indicated that resident (R1) had visitors after admission to the facility. (Continue on 9099C...) Unsubstantiated Facility not allowing resident to receive phone calls. Interview with staff and residents revealed that residents are receiving phone calls. After reviewing phone logs, LPAs observed resident (R1) was receiving phone calls. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 15-AS-20240318092143

Type of visit: Required - 1 Year

On 8/27/2024 at 9:00AM, Licensing Program Analysts (LPAs) G. Luk and P. Manalo arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Executive Director, Eunice O'Farrell and explained the purpose of the visit. LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, activity room, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 2/13/2024. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food supplies once a week. Freezer’s temperature was registered at -2 degree F while the refrigerator’s temperature was recorded at 36 degrees F. Hot water temperature was measured at 111.1 degrees F in a resident's bathroom sink. Grab bars and non-skid mat/materials were observed. There were adequate lights in each room. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 6/13/2024. LPAs reviewed 5 residents and 5 staff files starting at 10:25AM. LPAs interviewed 3 residents and 3 staff starting at 2:00PM. LPA reviewed a sample of resident's medications starting at 3:00PM. At 12:30PM, LPAs observed S3 did not have current annual training completed. At 3:30PM, LPAs observed S6 was not fingerprint cleared. LPAs reviewed Guardian system and observed S6's determination status was "closed - incomplete application". The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 27, 2024

Allegation investigated: Facility staff overdosed resident on medication. Facility staff did not attend to residents in a timely manner after falling. Facility staff leave residents in urine and feces for extended periods of time.

On 1/12/2024 at 1:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegations above. LPA met with Executive Director, Eunice O'Farrell and explained to her the reason for the visit. During the investigation, LPA interviewed 7 staff and complainant. LPA reviewed and obtained documents including staff roster with contact information, physician's report, care plan, incident reports, medication list, MAR, discharge documents, pull cord records, and care notes. Facility staff overdosed resident on medication. After reviewing R7's MAR, LPA observed R7 was given medications according to doctor's orders. R7's care notes did not indicate R7 was given overdosage of medications. Interview with staff revealed that med techs followed doctor's order when given medications to R7 and denied of giving overdose of medications to R7. (Continue on 9099C...) Unsubstantiated Facility staff did not attend to residents in a timely manner after falling. After reviewing a sample of resident's pull cord records, LPA observed staff response time to pull cords is less than 16 minutes. Interview with staff indicated there hasn't been an incident where pull cord response time is an hour or more. Facility staff leave residents in urine and feces for extended periods of time. Interview with staff revealed that resident's diaper checks are 2-3 hours and some residents are checked more frequent. Staff stated there hasn't been an incident where resident is left in soiled diaper for an extended periods of time. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jan 12, 2024 · control 15-AS-20230329161525

Type of visit: Case Management - Deficiencies

On 1/12/2023 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Executive Director, Eunice O'Farrell. During the course of investigation for complaint (#15-AS-20230329161525), the following deficiency was observed. LPA reviewed Guardian and observed S1 is not fingerprint cleared. Civil penalty of $500 is being assessed. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jan 15, 2024

Criminal Record Clearance. Obtain a California clearance or a criminal record exemption as required by the Department or... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by having uncleared staff work at the facility which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: S1 was asked to leave the facility. Facility has agreed to obtain fingerprint clearance for S1 prior to S1 returning to the facility. Facility will submit correspondence with CCLD regarding S1's clearance or S1's life scan form to CCLD by POC date. Civil penalty of $500 is being assessed.

Allegation investigated: Facility did not safeguard resident's personal belongings.

On 9/29/2023 at 10:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegation above. Upon arrival, LPA met with Assistant Executive Director, Eunice O'Farrell and explained to her the reason for the visit. During the course of the investigation, LPA conducted interviews with staff, residents, and complainant. Resident’s physician’s report, care plan, progress notes, LIC621, reimbursement information, and email correspondence were obtained and reviewed. LPA observed R1's progress notes stated that R1 was missing items including picture frames, clothing, iPod, and hearing aids with safety clips. LPA observed R1's LIC621 stated facility is entrusted with R1's hearing aids and safety clips. R1's hearing aids have safety clips that could be attached to R1's clothing. Interview with staff revealed that resident's belongings are usually labeled. Staff stated that hearing aids were not found and facility reimbursed R1's family for the cost of the hearing aids. (Continue LIC9099C...) Substantiated Resident suffered multiple falls resulting in injuries. Interview with staff revealed that R1 had six falls while living at the facility in which four falls resulted in injuries or minor injuries. However, after R1’s fall on 5/22/2022, the facility raised R1’s level of care from a two to a four which increased resident checks to eight times, R1 is checked every 30 minutes due to fall risk, and fall alarms was installed in R1’s room. Resident was not provided assistance with toileting needs Interview with staff indicated that toileting needs are checked at least every 2 hours. Staff have not witnessed resident's toileting needs were not met. Resident was not provided assistance with showering. Interview with staff revealed that R1 would sometimes refuse showers and staff come back at a later time to assist R1 with showers. Staff stated when a resident refused showers, it would be documented on the progress notes. Inadequate staffing to meet the needs of the residents in care. LPA reviewed staff scheduled and observed AM shift have 4-5 caregivers and 1 med tech, PM shift have 4 caregivers and 1 med tech, and NOC shift have 2 caregivers and 1 med tech. Interview with staff revealed that besides the caregivers and med techs, a manager is on duty for both AM and PM shift seven days a week. Staff did not respond to resident's call bell. LPA reviewed a sample of resident's pull cord records and observed pull cord incidents from R1 were responded by facility staff. Resident cannot easily use pull cord. LPA observed R4 demonstrated how to pulled on the pull cord beside the bed and was able to pull the pull cord. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 15-AS-20221229131014

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Oct 20, 2023

Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not safeguarding resident's belongings which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Facility has agreed to develop a plan to better safeguard resident's belongings in the future and submit plan to CCLD by POC date.

Type of visit: Case Management - Deficiencies

On 9/29/2023 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Assistant Executive Director, Eunice O'Farrell. During the course of investigation for complaint (#15-AS-20221229131014), the following deficiency was observed. Interview with staff (S2) revealed that facility did not always submit an incident report for R1's falls. LPA observed only 3 incident reports regarding R1's fall. However, R1 had other falls that was not reported to CCLD. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 20, 2023

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not reporting all of R1's falls which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Facility has agreed to conduct a training regarding reporting requirements. Facility will submit staff sign in sheet and training materials to CCLD by POC date.

Type of visit: Case Management - Annual Continuation

On 9/29/2023 at 2:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation. LPA met with Assistant Executive Director, Eunice O'Farrell and explained the purpose of the visit. During visit, LPA reviewed staff training and observed staff completed training which includes dementia, food service, resident rights, medication, hospice, ADL (Activities of Daily Living) care, and other topics. LPA interviewed 2 residents and 2 staff starting at 4:00PM. At around 5:30PM, LPA reviewed a sample of resident's medications. At 3:30PM, LPA observed facility does not have home health written agreement for a resident. At 6:00PM, LPA observed R4's doctor's order dated 4/11/2023 stated R4 is taking Acetaminophen 1000mg. However, LPA observed facility has a bottle of Acetaminophen 325mg. R4 also has a bottle of Acetaminophen 500mg. Facility has faxed R4's doctor the medication clarification/request and provided a copy to LPA during inspection. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 29, 2023

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.