011440744-9-14-2023-15-AS-ADEO-CVP3VT-20230914183541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 011440744
Report Date: 09/14/2023
Date Signed: 09/14/2023 06:35:48 PM

Document Has Been Signed on 09/14/2023 06:35 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 II		FACILITY NUMBER:	011440744
ADMINISTRATOR:	VIDICAN, GEORGE		FACILITY TYPE:	735
ADDRESS:	547 CHERRY WAY		TELEPHONE:	(510) 481-8871
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY: 6		CENSUS: 2	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	George Vidican/Licensee-Administrator		TIME COMPLETED:	06:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day, September 14, 2023, at 3:20 p,m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with licensee-administrator, George Vidican, and informed the reason for visit. Licensee submitted the facility's completed IC9282 Infection Control Plan which LPA received on 10/17/22. 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. Fire extinguisher checked and observed fully charge with tag showed serviced June 6. 2023. Hot water temperature in building # 2 was tested and measured at 109.4 degrees Fahrenheit. Facility conducts fire drill every month and records showed last conducted August 5, 2023. Facility has 2 in 1 carbon monoxide and smoke detector that was tested and observed functional. LPA reviewed 1 staff file and 2 residents records, and interviewed 1 staff and 2 residents. Residents' P&I cash compared with records. Medications and records checked. LPA observed the following: -At 3:35 pm, boxes on top of sofas in the living room, soiled carpet in the hallway in building # 1, chipped linoleum flooring in buidling # 2, empty pails and old wood planks in the backyard. -At 5:20 pm, R1 and R2's LIC625 Appraisal/Needs and Services Plan were dated 2019. At 5:23 pm, R1 and R2's LIC622 Centrally Stored Medication and Destruction Record do not have dates when medications were started. ...continued on 809C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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: 09/14/2023

NARRATIVE

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Licensee to submit the following updated documents by September 28, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed.

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: 09/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/14/2023 06:35 PM - It Cannot Be Edited

Created By: Alicia Delmundo On 09/14/2023 at 05:44 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: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building 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 visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for boxes on top of sofas in the living room and soiled carpet in the hallway in building # 1, chipped linoleum flooring in buidling # 2, empty pails and old wood planks in the backyard which pose a potential safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	Licenseee stated he'll have the living room and carpet cleaned, chipped linoleum replaced, and yard cleaned. Pictures to be submitted by 10/05/2023.

Type B

Section Cited

CCR

85068.3(a)

Modifications to Needs and Services Plan

(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above for 2 out of 2 residents' LIC625 more than 3 years old which pose a potential health and/or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	Licensee to update the LIC625, and submit copies by 10/05/2023.

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: 09/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/14/2023 06:35 PM - It Cannot Be Edited

Created By: Alicia Delmundo On 09/14/2023 at 05:59 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: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80070(a)

80070 Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 2 out of 2 residents' LIC622 incomplete for not having dates medications were started which pose a potential personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	Licensee to have the records completed, and submit self-certification by 10/05/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 09/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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