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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440744
Report Date: 08/29/2024
Date Signed: 08/29/2024 05:02:40 PM

Document Has Been Signed on 08/29/2024 05:02 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/
DIRECTOR:		VIDICAN, GEORGEFACILITY TYPE:
735
ADDRESS:547 CHERRY WAYTELEPHONE:
(510) 481-8871
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 1DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:George Vidican/Licensee-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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On this day, August 29, 2024, at 2:30 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 LIC9282 Infection Control Plan which LPA received on 10/17/22.

LPA toured the facility inside out with licensee. LPA inspected the front building, including but not limited to the living room, dining area, kitchen, bedrooms, bathroom and yard. 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. Hot water temperature was tested and measured at 105 degrees Fahrenheit. Facility conducts fire drill every month and records showed last conducted August 10, 2024. Facility has 2 in 1 carbon monoxide and smoke detector that was tested and observed functional.

LPA reviewed 1 staff and 1 resident file. Resident's P&I checked and compared with last recorded balance. Medications inspected and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record

LPA observed the following:
-at 2:49 pm, soiled carpet in the living room, resident's room and hallway.
-at 2:55 pm, sink in the kitchen not draining properly.

...continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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: 08/29/2024
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Licensee to submit the following updated/current documents by September 12, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

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 penalty.

Deficiency and plan and proof of correction 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: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2024 05:02 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/29/2024 at 04:42 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: 08/29/2024

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
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Based on observation, the licensee did not comply with the section cited above in soiled carpet flooring in the living room, resident's room and hallway, and sink not properly draining which pose a potential health and/or personal rights risks to person in care.
POC Due Date: 09/12/2024
Plan of Correction
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Licensee to have the carpet cleaned and fix the kitchen sink drain. Pictures to be submitted by 9/12/24.
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: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


LIC809 (FAS) - (06/04)
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