<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440823
Report Date: 04/07/2023
Date Signed: 04/07/2023 04:49:07 PM

Document Has Been Signed on 04/07/2023 04:49 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: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:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Care Staff- Rosario,MababaTIME COMPLETED:
05:00 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 4/7/2023 starting at 9:40 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Care Staff- Rosario,Mababa and explained the purpose of the visit. Administrator currently obtains a valid certificate which expires on 8/4/2024. The facility’s fire clearance was approved for all six (6) ambulatory clients. Upon entry, LPA observed one (1) staff and three (3) clients present during inspection. At 10:30AM, Robert I, Laguna Administrator (ADM) gave consent to staff member to tour and sign the report on his behalf.

Starting at 10:00 AM, LPA toured facility with care staff including but not limited to four (4) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are private, and 1 bedrooms is shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. Clients’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Sharps were locked and inaccessible to clients'.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 10/25/2022. First aid kit was observed to be complete.

Starting At 11:40 AM, LPA reviewed the two (2) of three (3) staff records. At 12:30 PM, LPA reviewed three (3) of (3) clients' records. At 2:30 PM, LPA reviewed a sample of 2 of 3 clients' medications.



Continue on Lic809-C (Page 1 of 2)
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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 7
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: 04/07/2023
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
26
27
28
29
30
31
32
Continued from Lic809 (Page 2 of 2)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

1. At 10:11 AM, LPA observed staff medication in the kitchen cabinet unlocked.
2. At 10:18 AM, LPA observed hot water measuring at 149.2 Degrees F. in common area bathroom
3. At 10:25 AM, LPA observed the hinge of the backyards gate is in disrepair and is difficult to open.
4. At 11:08 AM, LPA observed unlocked Clorox cleaning solution in the garage cabinet.
5. At 12:10 PM, LPA observed S2 does not have current first aid and CPR training; First aid and CPR expired on 8/2013.
6. At 1:30 PM, LPA observed during record review that C1, C2, and C3 have no functional capability assessment done.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/14/2023:
    1. LIC 308 Designation of Administrative Responsibility
    2. LIC 309 Administrative Organization
    3. LIC 500 Personnel Report
    4. LIC 610D Emergency Disaster Plan (9 Pages)
    5. Liability Insurance
    6. LIC9282 Infection Control Plan.




Exit interview conducted with care staff, and a copy of this report provided along with appeal rights.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/07/2023 04:49 PM - It Cannot Be Edited


Created By: Liridon Fici On 04/07/2023 at 03:56 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: 04/07/2023

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having unlocked Clorox cleaning solution located in the garage cabinet that is accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2023
Plan of Correction
1
2
3
4
Deficiency cleared.

Care staff locked up the Clorox cleaning solution which was located in the cabinet in the garage.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 in not maintaining proper hot water temperature in between 105-120 Degree F. in common area bathroom and was measured at 149.2 Degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2023
Plan of Correction
1
2
3
4
Administrator agreed to reduce the hot water temperature in the common area bathroom and to submit a photo of the hot water to CCL 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: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/07/2023 04:49 PM - It Cannot Be Edited


Created By: Liridon Fici On 04/07/2023 at 03:56 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: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in not locking up staff medication located in the kitcken cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2023
Plan of Correction
1
2
3
4
Deficiency cleared.

Care staff locked up medication in the kitchen drawer. Medication is no longer assessible to clients in care.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/07/2023 04:49 PM - It Cannot Be Edited


Created By: Liridon Fici On 04/07/2023 at 03:56 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: 04/07/2023

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 by not repairing the hinge of the gate in the backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
1
2
3
4
Administrator agreed to repair the gate's hinge in the backyard for the gate to open and close properly and to submit a photo picture to CCL by POC due date.
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, and record review, the licensee did not comply with the section cited above by not maintaining current Functional Capability Assessments for C1, C2, and C3 in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
1
2
3
4
Administrator agreed to review section 85068.2(b)(1)- Needs and Service Plan and to fill out a Functional Capability Assessments for C1, C2, and C3 and to submit a copy to CCL 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: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/07/2023 04:49 PM - It Cannot Be Edited


Created By: Liridon Fici On 04/07/2023 at 03:56 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: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85165(f)(7)
Emergency Intervention Staff Training
(f) The administrator who will approve the continued use of a manual restraint or seclusion shall complete additional training which shall include the following: (7) Current first aid certification and current certification in the use of cardiopulmonary resuscitation (CPR).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in not renewing First aid and CPR training for S2 that expired on 8/2013 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
1
2
3
4
Administrator agree to renew First aid and CPR training for S2 and submit a copy to CCL by POC due date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7