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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440823
Report Date: 05/26/2022
Date Signed: 05/26/2022 02:32:59 PM

Document Has Been Signed on 05/26/2022 02:32 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:BESCO GARDENFACILITY NUMBER:
011440823
ADMINISTRATOR:LAGUNA, ROBERT I.FACILITY TYPE:
735
ADDRESS:40242 CROCKETT STREETTELEPHONE:
(510) 226-8813
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 3DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Care staff-Rosario MababaTIME COMPLETED:
02:35 PM
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On 05/25/2022 at 10:30am, Licensing Program Analysts (LPAs) L. Fici & L. Hall arrived unannounced to conduct an annual Infection Control Inspection. LPAs met with care staff, Rosario Mababa and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility with staff member including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. There is one central entry point for universal screening for staff, residents, and visitors. LPAs observed no sign-in policy. LPAs observed thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Water temperature was maintained in hallway bathroom at 117.1 degree F. Bathrooms are equipped with liquid soap. Trash bins don't have any foot pedals. Facility staff were observed to be wearing proper PPE. Facility does not have a 30-day supply of PPEs. Facility has a mitigation plan. Fire extinguisher last serviced 10/12/2021. Passages inside and out were free of obstruction.

Continue on LIC809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: BESCO GARDEN
FACILITY NUMBER: 011440823
VISIT DATE: 05/26/2022
NARRATIVE
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Continued from LIC809.

The following forms are to be updated and submitted to CCLD By 06/2/2022.
- LIC500- Personnel Report
- LIC308- Designation of Administrative Responsibility
- LIC610D- Emergency Disaster Plan
- updated facility roster

The following deficiencies were observed:

10:34- LPAs observed refrigerator unsanitary.
10:35am- LPAs observed insufficient amount of 7 day non- perishable, and 2 day perishable foods.
10:40am- LPAs observed knifes unlocked in kitchen draw near the sink.
10:43am- LPAs observed Ajax on the window sill. LPAs observed laundry detergent under the kitchen sink unlocked.
11:03am- LPAs observed rusty nails and 2 pairs of scissors located in the enclosed patio.
11:04am- LPAs observed bathroom tub floor and toilet unsanitary.
11:59am- LPAs observed administrator not present on the premises for a number of hours necessary.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeals rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/26/2022 02:32 PM - It Cannot Be Edited


Created By: Liridon Fici On 05/26/2022 at 12:35 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: BESCO GARDEN
FACILITY NUMBER: 011440823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087(g) Buildings 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 having inaccessible Sharps and toxins, which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator agreed to locking all sharps and toxins away from residents in care to CCL by POC date.

Sharps were locked in medication cabinet, and toxins were locked in the garage during inspection.
Deficiency cleared.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/26/2022 02:32 PM - It Cannot Be Edited


Created By: Liridon Fici On 05/26/2022 at 12:51 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: BESCO GARDEN
FACILITY NUMBER: 011440823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
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 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 not having a cleaned refrigerator, and bathroom that is unsanitary, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Administrator agreed to clean refrigerator and bathroom by making it sanitary to all persons in care and to submit a photo copy to CCL by POC due date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/26/2022 02:32 PM - It Cannot Be Edited


Created By: Liridon Fici On 05/26/2022 at 12:55 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: BESCO GARDEN
FACILITY NUMBER: 011440823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service:
(d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 having an insufficient amount of perishables and non- perishable foods which poses a potential health and safety risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Administrator to purchase 7 day perishable and 2 day perishable for facility and submit a copy of food and the receipt to CCL by POC due date.
Type B
Section Cited
CCR
85064(e)
(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.

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: LPAs observed administrator not present on the premises for a number of hours necessary, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2022
Plan of Correction
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Licensee will review the regulation and submit a self- certication to CCLD by POC due date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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