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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440339
Report Date: 06/25/2021
Date Signed: 06/25/2021 12:44:44 PM

Document Has Been Signed on 06/25/2021 12:44 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:PIROUNAKIS, INC.FACILITY NUMBER:
011440339
ADMINISTRATOR:MARY PIROUNAKISFACILITY TYPE:
735
ADDRESS:17031 RAGLAND ST.TELEPHONE:
(510) 276-2301
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 12CENSUS: 12DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Mary Pirounakis/Administrator TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Mary Pirounakis, administrator, and informed the purpose the visit. LPA also met with staff, Rowena Velasco, Marie Lopez and Antonella Baltazar.

LPA toured the facility inside and out with Mary Pirounakis. LPA inspected the living room, common area, resident rooms, bathrooms, kitchen, dining area, garage, side and backyards. Medications are centrally stored in a locked area that is inaccessible to residents and refilled every 30 days. Perishable and non-perishable food supplies were observed sufficient. Personal protective equipments (PPEs) were observed sufficient for 30 days.

Water temperature was tested in one of the bathrooms and measured at 109.5 degrees Fahrenheit. Fire extinguishers checked, observed fully charge and tags showed serviced December 10, 2020. .

The following updated/current documents to be submitted by July 9, 2021:
1. LIC610D Emergency Disaster Plan
2. Proof of surety bond coverage

LPA verified and Mary indicated facility has not done N95 fit testing of staff.



.....continued next page (809C)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2021
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: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339
VISIT DATE: 06/25/2021
NARRATIVE
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LPA observed the following:
1. Expired salami (expiration: May 26, 2020 and November 16, 2020) and Bologna (expiration: January 24, 2020).
2. There's no cough/sneeze etiquette poster in some of the areas in the facility. There's also no droplet precautions poster anywhere in prominent place in the facility and visitor's poster is outdated.

Deficency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date along with the LIC9098 Proof of Correction form, and any repeat violations within 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Mary Pirounakis.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2021 12:44 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/25/2021 at 12:05 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: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(1)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Bologna and salami are expired which poses an immediate health risk to persons in care.
POC Due Date: 06/26/2021
Plan of Correction
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Administrator to have all the food supplies checked and in-service the staff. Proof to be submitted by 6/26/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021


LIC809 (FAS) - (06/04)
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