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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440781
Report Date: 04/11/2024
Date Signed: 04/11/2024 05:49:49 PM

Document Has Been Signed on 04/11/2024 05:49 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:CROUSE HOMES, INC., THEFACILITY NUMBER:
011440781
ADMINISTRATOR/
DIRECTOR:		LAURA A CARTERFACILITY TYPE:
735
ADDRESS:237 CHERRY WAYTELEPHONE:
(510) 317-9016
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 15CENSUS: 14DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Laura Carter/Administrator TIME VISIT/
INSPECTION COMPLETED:
05:55 PM
NARRATIVE
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On this day, April 11, 2024, at 1:15 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Laura Carter, administrator, and informed the reason for visit. LPA also met with staff, Zenaida Siwa and House Manager Hilario 'Larry' Siwa.

Administrator submitted copy of LIC9282 Infection Control Plan which LPA received on July 21, 2023.

LPA toured the facility inside and out with the administrator. The facility comprises of a 2 level building, a detached cottage and detached storage/office. LPA inspected the bedrooms, bathrooms, kitchen, dining and living rooms, detached storage/office and residents' room in detached cottage. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Fire extinguishers were observed fully charge with tags showed serviced November 15, 2023. Facility has carbon monoxide and smoke detectors that were tested and observed functional. Hot water temperature in one of the common bathrooms was tested and measured at 106.7 degrees Fahrenheit. Facility conducts fire drill monthly and earthquake drill every quarter, and records showed last conducted March 29, 2024 and January 21, 2024 respectively.

LPA reviewed 5 residents and 4 staff files, and interviewed 3 residents and 2 staff. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Records. Residents' P&I were checked and compared with the last recorded balance.


.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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: CROUSE HOMES, INC., THE
FACILITY NUMBER: 011440781
VISIT DATE: 04/11/2024
NARRATIVE
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LPA observed the following:
- at 1:55 p.m., storage in the yard where cleaning supplies are kept was unlocked.
-at 2:10 p.m., no evacuation chair.
-at 4:15 to 4:30 p.m., quantity of residents' (R2 and R3) of medications received did not match the quantity on labels on the medications; actual quantity received from the pharmacy were less than the quantity on the labels.

On this same day, LPA obtained copies of the following updated/current documents:
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, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed the administrator and house manager.

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: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/11/2024 05:49 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/11/2024 at 05:00 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: CROUSE HOMES, INC., THE
FACILITY NUMBER: 011440781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 storage for cleaning supplies unlocked.which poses an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Administrator locked the storage.
In addition, administrator to in-service the staff, and submit copy on training topic with attendees signatures by 4/12/24.
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: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/11/2024 05:49 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/11/2024 at 05:00 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: CROUSE HOMES, INC., THE
FACILITY NUMBER: 011440781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(3)
Health-Related Services
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in R2 and R3's quantity on medication labels not matching the actual quantity received which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Administrator to obtain correct labels from pharmacy, and send self-certification by 4/25/24.
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

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 for not having an evacuation chair which pose a potential safety and/or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Administrator to purchase an avacuation chair, and submit proof by 4/25/24.
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: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
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