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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600841
Report Date: 06/25/2026
Date Signed: 06/25/2026 08:28:56 PM

Document Has Been Signed on 06/25/2026 08:28 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:LAFAYETTE CARE HOMEFACILITY NUMBER:
075600841
ADMINISTRATOR/
DIRECTOR:		LINDA LI KURIHARAFACILITY TYPE:
740
ADDRESS:3640 BAKER LANETELEPHONE:
(925) 299-8801
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY: 6CENSUS: 4DATE:
06/25/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:25 PM
MET WITH:Linda Kurihara/Administrator TIME VISIT/
INSPECTION COMPLETED:
08:30 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Delmundo conducted a case management to ensure the health and safety of residents as a result of the Department receiving a Priority 2 complaint (Complaint Control # 15-AS-20260622132459). Upon arrival to the facility and review of records and conducting inspection, LPA observed and learned the following:
  • staff (S1) left the facility at around 4:15 pm with only S1's friend (F1) at the facility with the four residents. F1 is not fingerprinted and stated she does not work at the facility. S1 arrived at 5:10 pm and Linda Kurihara, administrator (ADM) at 5:20 pm.
  • unlocked kitchen cabinet where medications are stored.
  • medication out in the open in the formal dining room.
  • unlocked kitchen cabinet where cleaning supplies are kept.
  • unlocked kitchen drawer where sharps are stored and knife in the dish drainer.
  • unlocked cabinet in the bathroom where including but not limited to the following were stored: Drano clog remover; insect killer; shower and mirror glass cleaner; Ajax cleanser; Pledge spray.
  • resident's (R1) was placed on hospice care on February 20, 2026 but R1's LIC625 Appraisal/Needs and Services not updated. LIC625 on file was dated February 20, 2020.
  • R1 sustained bruises but ADM stated she did not submit LIC624 Unusual Incident Report,



....continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: LAFAYETTE CARE HOME
FACILITY NUMBER: 075600841
VISIT DATE: 06/25/2026
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CONTINUED FROM PAGE 1:

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 1569.312(a). Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in additional civil penalties.

Deficiencies, plan and proof of corrections and civil penalty were with the administrator (ADM).

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2026 08:28 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/25/2026 at 07:31 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: LAFAYETTE CARE HOME
FACILITY NUMBER: 075600841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2026
Section Cited
CCR
1569.312(a)

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ยง1569.312 Basic services requirements:
Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2.

-This requirement is not met as evidenced by:
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Administrator to in-service the staff and ensure there's always staff with the residents. Proof to be submitted by 6/26/26.

A $500.00 civil penalty is assessed.
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-Based on observation and interviews, the licensee did not comply with the section above when the staff left the residents which posed an immediate health, safety and/or personal rights risks to persons in care,
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Type A
06/26/2026
Section Cited
CCR87309(a)

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87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage...
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Staff locked the knife and cabinets.

In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 6/26/26.
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....and are not left unattended if outside the locked storage.
-This requirement is not met as evidenced by;
-Based on observation, the licensee did not comply with the section above in unlocked cabinets & drawers where cleaning supplies and sharps were kept & knife in the dish drainer.
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


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Document Has Been Signed on 06/25/2026 08:28 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/25/2026 at 07:40 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: LAFAYETTE CARE HOME
FACILITY NUMBER: 075600841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2026
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care: (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....
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Staff locked the cabinet.

In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 6/26/26.
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.. medication.
-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above in unlocked central storage for medication and medication in the formal dining area which posed an immediate health and/or personal right risks to persons 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2026 08:28 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/25/2026 at 07:46 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: LAFAYETTE CARE HOME
FACILITY NUMBER: 075600841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2026
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within....
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Resident is no longer at the facility.
Administrator to do the following and submit proof by 7/09/26:
1. Read the Regulations and submit self-certifcation of understanding of timely reporting.
2. Submit LIC624
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...seven days of the occurrence of any of the events...
-This requirement was not met as evidenced by:
-Based on interview, the licensee did not comply with the section above when report was not submitted when R1 was observed with bruises.
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Type B
07/09/2026
Section Cited
CCR87463(a)

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87463 Reappraisals: (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions,...
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Resident is no longer at the facility.

Administrator tp read the Regulations and submit self-certifcation of understanding by 7/09/26.
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... and to keep the appraisal accurate.
-This requirement was not met as evidenced by:
-Based on record review and interview, the licensee did not comply with the section above in not updating R1's LIC625 which posed a potential health, safety and/or personal rights 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


LIC809 (FAS) - (06/04)
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