Inspection Reports for Carefield Pleasanton Memory Care
4115 Mohr Ave, Pleasanton, CA 94566, United States, CA
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies, with issues primarily related to staff fingerprint clearance, training, and safety concerns such as hot water temperature and resident supervision. Several complaint investigations were unsubstantiated, including allegations about visitation restrictions and medication errors. The facility received a $500 civil penalty in January 2024 for employing a staff member without fingerprint clearance. The most recent report from August 12, 2025, cited a deficiency for hot water temperature exceeding allowed limits, posing an immediate health and safety risk. There is no clear pattern of improvement or decline, as deficiencies have appeared intermittently over time.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 49
Capacity: 82
Deficiencies: 1
Aug 12, 2025
Visit Reason
The inspection was an unannounced Required - 1 Year inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The inspection found that the facility generally met regulatory requirements including safety equipment, emergency plans, and food storage. However, a deficiency was cited for hot water temperature exceeding the allowed maximum, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Hot water temperature in a resident's bathroom was measured at 130.4 degrees F, exceeding the maximum allowed temperature and posing an immediate health and safety risk. | Type A |
Report Facts
Hot water temperature: 130.4
Hot water temperature: 111.4
Facility capacity: 82
Census: 49
Fire extinguisher last serviced: Jan 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eunice O'Farrell | Executive Director | Met with Licensing Program Analyst during inspection |
| Grace Luk | Licensing Program Analyst | Conducted the inspection and signed the report |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 82
Deficiencies: 1
Jan 24, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report received on 2025-01-23 regarding a resident who was found outside the facility unassisted.
Findings
The inspection found that a resident left the facility unassisted due to a door being left propped open, which violated the California Code of Regulation, Title 22. This deficiency was cited and poses a potential health and safety risk.
Complaint Details
The complaint was substantiated based on the incident report and investigation showing a resident left the facility unassisted, contrary to physician's orders and safety regulations.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. Licensee did not comply by having a resident leave the facility unassisted. | Type B |
Report Facts
Deficiency count: 1
Plan of Correction due date: Feb 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eunice O'Farrell | Executive Director | Met with Licensing Program Analyst during inspection and named in relation to the incident and findings. |
| Grace Luk | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Census: 49
Capacity: 82
Deficiencies: 0
Jan 24, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to a death report received on 2025-01-20.
Findings
The inspection found that a resident (R1) was found unresponsive and later passed away at the hospital on 2025-01-15. Staff followed appropriate procedures including calling 911 and notifying family. No deficiencies were cited during this visit.
Report Facts
Facility capacity: 82
Resident census: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eunice O'Farrell | Executive Director | Met with Licensing Program Analyst during inspection |
| Grace Luk | Licensing Program Analyst | Conducted the case management visit |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 82
Deficiencies: 0
Aug 27, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that the facility was not allowing family members to visit residents and was not allowing residents to receive phone calls.
Findings
The investigation found that family members do visit residents and residents are receiving phone calls. After reviewing visitor logs and phone call records, the allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated as evidence showed residents were receiving visitors and phone calls as alleged restrictions were not occurring.
Report Facts
Capacity: 82
Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| Eunice O'Farrell | Executive Director | Met with investigators during the visit |
| Parveen Singh | Administrator | Facility administrator named in report header |
Inspection Report
Annual Inspection
Census: 45
Capacity: 82
Deficiencies: 2
Aug 27, 2024
Visit Reason
The inspection was an unannounced Required - 1 Year inspection conducted to evaluate compliance with licensing regulations.
Findings
The inspection found deficiencies related to staff training and fingerprint clearance. Specifically, one staff member (S3) did not have current annual training completed, and another staff member (S6) was not fingerprint cleared, posing potential health and safety risks.
Deficiencies (2)
| Description |
|---|
| Staff member S3 did not have current annual training completed as required by HSC 1569.625(b)(2). |
| Staff member S6 was not fingerprint cleared prior to employment, violating CCR 87411(g)(1), posing an immediate health and safety risk. |
Report Facts
Capacity: 82
Census: 45
Civil penalty: 500
Plan of Correction Due Date: Due date for S3 training correction is 2024-09-13.
Plan of Correction Due Date: Due date for S6 fingerprint clearance correction is 2024-08-28.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Parveen Singh | Administrator/Director | Facility administrator named in the report header. |
| Eunice O'Farrell | Executive Director | Met with Licensing Program Analysts during inspection and agreed to plans of correction. |
| Grace Luk | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Harpreet Humpal | Licensing Program Manager/Supervisor | Supervisor of the inspection and named in the report. |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 82
Deficiencies: 0
Jan 12, 2024
Visit Reason
Unannounced complaint investigation conducted due to allegations including medication overdose, untimely staff response after resident falls, and residents being left in urine and feces for extended periods.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Medication administration was according to doctor's orders, staff response times to pull cords were less than 16 minutes, and diaper checks occurred every 2-3 hours or more frequently.
Complaint Details
The complaint investigation was unsubstantiated as evidence did not prove the alleged violations occurred.
Report Facts
Capacity: 82
Census: 38
Staff response time: 16
Diaper check frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| Eunice O'Farrell | Executive Director | Met with Licensing Program Analyst during investigation |
| Parveen Singh | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 82
Deficiencies: 1
Jan 12, 2024
Visit Reason
The visit was an unannounced case management inspection conducted during the course of investigation for complaint #15-AS-20230329161525.
Findings
A deficiency was observed where staff member S1 was not fingerprint cleared, which is a violation of California Code of Regulations, Title 22. A civil penalty of $500 was assessed.
Complaint Details
The visit was triggered by complaint #15-AS-20230329161525. The deficiency related to fingerprint clearance was substantiated and a civil penalty was assessed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff member S1 is not fingerprint cleared, posing an immediate health and safety risk. | Type A |
Report Facts
Civil penalty amount: 500
Capacity: 82
Census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eunice O'Farrell | Executive Director | Met with Licensing Program Analyst during inspection |
| Grace Luk | Licensing Program Analyst | Conducted the inspection and cited deficiency |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 82
Deficiencies: 1
Sep 29, 2023
Visit Reason
Unannounced complaint investigation conducted due to allegations including failure to safeguard resident's personal belongings, resident injury, multiple falls, inadequate assistance with toileting and showering, inadequate staffing, failure to respond to call bells, and difficulty using pull cords.
Findings
The investigation substantiated the allegation that the facility failed to safeguard a resident's personal belongings, posing a potential health and safety risk. Other allegations including resident injury, multiple falls, toileting and showering assistance, staffing adequacy, call bell response, and pull cord use were found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
Complaint investigation was triggered by multiple allegations including failure to safeguard resident belongings, resident injury, multiple falls, inadequate assistance with toileting and showering, inadequate staffing, failure to respond to call bells, and difficulty using pull cords. The allegation regarding safeguarding belongings was substantiated; others were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not safeguard resident's personal belongings, violating CCR 87217(b). | Type B |
Report Facts
Facility capacity: 82
Resident census: 38
Plan of Correction due date: Oct 20, 2023
Resident fall checks: 8
Resident falls: 6
Caregivers on AM shift: 4
Med techs on AM shift: 1
Caregivers on PM shift: 4
Med techs on PM shift: 1
Caregivers on NOC shift: 2
Med techs on NOC shift: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Harpreet Humpal | Licensing Program Manager | Oversaw complaint investigation |
| Parveen Singh | Administrator | Facility administrator named in report |
| Eunice O'Farrell | Assistant Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 38
Capacity: 82
Deficiencies: 2
Sep 29, 2023
Visit Reason
The visit was an unannounced Case Management - Annual Continuation inspection to review staff training, resident care, and compliance with regulations.
Findings
The inspection found deficiencies including the lack of a written home health agency agreement and medication discrepancies involving Acetaminophen dosages. The facility has submitted plans of correction and clarification requests to the physician.
Deficiencies (2)
| Description |
|---|
| Facility did not have a home health agency written agreement, posing a potential health and safety risk. |
| Medication discrepancy: doctor's order for Acetaminophen 1000mg but facility had bottles of 325mg and 500mg. |
Report Facts
Capacity: 82
Census: 38
Plan of Correction Due Date: Oct 20, 2023
Plan of Correction Due Date: Sep 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted the inspection and authored the report |
| Harpreet Humpal | Licensing Program Manager | Supervised the inspection |
| Eunice O'Farrell | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Narcisa Gordillo | Memory Care Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 82
Deficiencies: 1
Sep 29, 2023
Visit Reason
The visit was an unannounced case management inspection conducted during the course of investigation for complaint #15-AS-20221229131014.
Findings
The facility failed to submit incident reports for all falls experienced by resident R1, with only three falls reported despite additional unreported falls. This deficiency was cited under California Code of Regulations, Title 22.
Complaint Details
The visit was complaint-related, investigating complaint #15-AS-20221229131014. The deficiency involved failure to report all falls of resident R1, posing a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit incident reports for all of resident R1's falls. | Type B |
Report Facts
Incident reports observed: 3
Plan of Correction Due Date: Oct 20, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eunice O'Farrell | Assistant Executive Director | Met with Licensing Program Analyst during the inspection. |
| Grace Luk | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Harpreet Humpal | Licensing Program Manager | Named as supervisor and licensing program manager in the report. |
Inspection Report
Annual Inspection
Census: 39
Capacity: 82
Deficiencies: 3
Aug 29, 2023
Visit Reason
The inspection was an unannounced Required - 1 Year annual inspection conducted to evaluate compliance with licensing regulations.
Findings
The inspection found deficiencies including missing TB test results for two residents, lack of current first aid training for one staff member, and an initial hot water temperature that was too high but was corrected during the visit.
Deficiencies (3)
| Description |
|---|
| Missing TB test results for residents R2 and R3, posing a potential health and safety risk. |
| Staff member S4 did not have current first aid training, posing a potential health and safety risk. |
| Hot water temperature in a resident's bathroom was measured at 126 degrees F, exceeding the maximum allowed temperature and posing an immediate health and safety risk; corrected during inspection. |
Report Facts
Deficiencies cited: 3
POC Due Date: Sep 13, 2023
POC Due Date: Aug 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Narcisa Gordillo | Memory Care Director | Met with Licensing Program Analyst during inspection and exit interview. |
| Grace Luk | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 82
Deficiencies: 0
Dec 30, 2022
Visit Reason
The inspection visit was conducted unannounced on 12/30/2022 as a health and safety check resulting from a priority 2 complaint.
Findings
The Licensing Program Analyst toured the facility and found all conditions satisfactory, including proper temperature controls, sufficient food supplies, secure medication storage, and functional safety equipment. No deficiencies were cited during this visit.
Complaint Details
Visit was triggered by a priority 2 complaint. No deficiencies were cited, indicating no substantiated violations.
Report Facts
Facility temperature: 69
Hot water temperature: 120
Non-perishable food supply: 7
Perishable food supply: 2
Refrigerator temperature: 36
Freezer temperature: -3
Capacity: 82
Census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eunice O'Farrell | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Grace Luk | Licensing Program Analyst | Conducted the inspection visit |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 82
Deficiencies: 0
Jul 28, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility failed to provide adequate supervision resulting in a resident pushing another resident.
Findings
The investigation included interviews with staff and a resident, and review of relevant documents. It was found that although the incident may have occurred, there was insufficient evidence to substantiate the allegation. No deficiencies were cited.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence proving the alleged violation occurred.
Report Facts
Facility capacity: 82
Census: 44
Staff on duty: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Parveen Singh | Senior Executive Director | Met with Licensing Program Analyst during investigation |
| Jocelyn Sanjuan | Business Office Director | Met with Licensing Program Analyst during investigation |
| Grace Luk | Licensing Program Analyst | Conducted complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 44
Capacity: 82
Deficiencies: 0
Jul 28, 2022
Visit Reason
The visit was an unannounced case management inspection conducted in response to a death report received on 2022-07-26 regarding a resident who passed away at the facility on 2022-07-22.
Findings
The Licensing Program Analyst reviewed the resident's file and physician's report, confirming the resident's diagnoses and circumstances of death. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Parveen Singh | Senior Executive Director | Met during the visit and involved in the case management inspection. |
| Jocelyn Sanjuan | Business Office Director | Met during the visit and involved in the case management inspection. |
| Grace Luk | Licensing Program Analyst | Conducted the case management visit. |
| Harpreet Humpal | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Routine
Census: 40
Capacity: 82
Deficiencies: 0
Jul 14, 2022
Visit Reason
The inspection was an unannounced infection control inspection conducted as a required one-year visit to assess compliance with infection control guidelines.
Findings
The facility was found to be in compliance with infection control practices, including proper use of PPE, hand hygiene, and COVID-19 screening protocols. No deficiencies were cited, and technical assistance was provided regarding infection control guidelines.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Parveen Singh | Senior Executive Director | Met with Licensing Program Analyst during infection control inspection. |
| Eunice O'Farrell | Assistant Executive Director | Met with Licensing Program Analyst during infection control inspection. |
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