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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440744
Report Date: 09/30/2022
Date Signed: 09/30/2022 06:58:39 PM

Document Has Been Signed on 09/30/2022 06:58 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:GEORGE'S HOME CARE IIFACILITY NUMBER:
011440744
ADMINISTRATOR:VIDICAN, GEORGEFACILITY TYPE:
735
ADDRESS:547 CHERRY WAYTELEPHONE:
(510) 481-8871
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 2DATE:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:George Vidican/Licensee-administratorTIME COMPLETED:
07:10 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with George Vidican, licensee-administrator, and informed the purpose of visit.

Facility has LIC808 Mitigation Plan on file. Licensee has not submitted the new Infection Control Plan.

LPA toured the facility inside out with licensee. Facility has 2 buildings. LPA inspected the 2 buildings including but not limited to the living room, dining area, kitchen, bedrooms, bathrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station located near the entrance with hand sanitizer, surgical masks and disposable gloves readily available; however, facility does not have no touch probe thermometer. Antigen test kits are readily available. COVID-19 signages were observed posted. Supplies of PPEs inspected.

Fire extinguisher checked and observed fully charge with tag showed serviced June 1, 2022. Hot water temperature was tested and measured at 105.4 degrees Fahrenheit.

LPA verified and licensee stated the following:
1. Visitors are not screened for Covid-19 symptoms.
2. Residents are not checked for symptoms.



.....continued next page
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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: GEORGE'S HOME CARE II
FACILITY NUMBER: 011440744
VISIT DATE: 09/30/2022
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LPA observed the following:
1. Living room in the front building cluttered.
2. Plywood in the hallway in the front building.
3. Construction tools in the common area in the back building.
4. Entrance door has no "Wear Mask" poster.

Licensee to submit the following by October 14, 2022:
1. Proof of surety bond coverage
2. LIC610D Emergency Disaster Plan (9 pages)
3. LIC9282 Infection Control Plan

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalties.

Deficiency and plan and proof of correction were discussed with licensee.

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

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2022 06:58 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/30/2022 at 06:26 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: GEORGE'S HOME CARE II
FACILITY NUMBER: 011440744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
80087 Buildings and Grounds:
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitor.

This requirement is not met as evidenced by:
Deficient Practice Statement
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--Based on inspection and observation, the licensee failed to keep the facility safe by having the contruction tools in the back buidling which poses an immediate safety risk to clients in care. LPA also observed the living room cluttered and a plywood in the hallway in the front building.
POC Due Date: 10/01/2022
Plan of Correction
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Licensee to do the following and submit pictures by 10/01/2022:
1. Remove and locked the construction tools.
2. Clear the living room.
3. Remove the plywood.
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: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022


LIC809 (FAS) - (06/04)
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