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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440744
Report Date: 10/18/2023
Date Signed: 10/18/2023 04:19:10 PM

Document Has Been Signed on 10/18/2023 04:19 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:
10/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:George Vidican/Licensee-administratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a Proof of Correction (POC) visit. LPA met with George Vidican, licensee-administrator, and informed the reason for visit.

On 9/14/23, LPA conducted an annual inspection and issued the following citations with POC to be submitted by 10/05/23:
1. Section # 80087(a) - pictures to be submitted showing living room and carpet cleaned, chipped linoleum replaced, and yard cleaned.
2. Section # 85068.3(a) - POC to submit copies of LIC625 Appraisal/Needs and Services Plan
3. Section # 80070(a) - POC to submit self-certification that the LIC622 Centrally Stored Medication and Destruction Records are completed.

Licensee submitted the LIC9098 Proof Correction form but without the POCs.

On this day, 10/18/23, LPA toured the facility and checked residents records and observed the following:
1. Section # 80087(a) - the carpet flooring cleaned and chipped linoleum flooring replaced; backyard cleaned; however, the living room is partially cleared.
2. Section # 85068.3(a) - records showed LIC625 updated.
3. Section # 80070(a) - records showed LIC622 updated.



..continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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: 10/18/2023
NARRATIVE
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Licensee to submit the following by November 1, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiency section # 80087(a) is re-cited on this day.

Deficiency and POC 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: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/18/2023 04:19 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/18/2023 at 03:28 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: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
80087(a)

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80087 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:
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Administrator to have the living cleared and submit picture by 11/01/23.
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-Based on observation, the licensee did not comply with the section above for living room partially cleared which poses a potential safety or personal rights risk to persons in care.
This is a deficiency is re-cited.
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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: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023


LIC809 (FAS) - (06/04)
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