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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440823
Report Date: 05/15/2024
Date Signed: 05/15/2024 05:54:57 PM

Document Has Been Signed on 05/15/2024 05:54 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BESCO GARDENFACILITY NUMBER:
011440823
ADMINISTRATOR/
DIRECTOR:		LAGUNA, ROBERT I.FACILITY TYPE:
735
ADDRESS:40242 CROCKETT STREETTELEPHONE:
(510) 226-8813
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 2DATE:
05/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Rosario Mababa, CaregiverTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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On 05/15/2024 at 3:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit. LPA met with Caregiver, Rosario "Chary" Mababa and explained the purpose for the visit.

While LPA L. Alexander was at the facility for a Plan of Correction (POC) visit and the following deficiencies was observed.

Client (C1) records were not available for review. LPA was informed that C1 has home health services and was hospitalized on 04/04/2024. This particular incident was not reported to CCLD. In addition, LPA was informed that C1 needs oxygen 24/7 and is unable to take the portable oxygen off it's charger unless someone else is there to remove the portable oxygen. C1 has an oxygen concentrator in his bedroom. At this time of the visit it is unclear if C1 has the ability to manage his oxygen on his own without assistance from staff. The Administrator was not available during the visit.

Documents obtained by LPA: C1's Hospital After Visit Summary (dated 04/05/24), Physician's Report (LIC 602 dated 10/30/19), Appraisal Needs and Services (dated 04/01/19) and RCEB IPP Addendum (dated 02/20/24).


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. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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 3
Document Has Been Signed on 05/15/2024 05:54 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/15/2024 at 04:37 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
85068.4(c)(3)

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Acceptance and Retention Limitations (c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file: (3) Documentation of a medical assessment, signed by a physician, made within the last year.

This requirement is not met as evidenced by:
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Administrator agree to submit Physician's Report for C1 by POC due date.
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Based on record review, the licensee did not comply with the section cited above in by not having an updated Physician's Report (LIC602A) for C1 which poses a potential health and safety risk to persons in care.
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Type B
05/22/2024
Section Cited
CCR80070(d)

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80070 Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
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Administrator agree to self certifiy that they read and understand the regulation and submit self-certification to CCLD by POC due date.
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Based on record review, the licensee did not comply with the section cited above in by not having C1's records available at the facility which poses a potential health and safety risk to persons in care.
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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:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/15/2024 05:54 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/15/2024 at 04:50 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
80075(e)(1)

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Health Related Services
(e) In adult CCFs, when a client requires oxygen the licensee is responsible for the following:
(1) Monitoring the client's ongoing ability to operate and care for the equipment in accordance with the physician's instructions, or if the client is unable to do so:


This requirement is not met as evidenced by:

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Administrator shall submit a detailed care plan to who is caring for C1's oxygen and submit this detailed plan to CCLD by POC due date.
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Based on observation and interview, the licensee did not comply with the section cited above in by having a detailed care plan on file of C1's oxygen use for which poses a potential health and safety risk to persons in care.
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Type B
05/22/2024
Section Cited
CCR80061(b)(E)

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Reporting Requirements
(b) Upon the occurrence, during the operation of the facility...shall be submitted to the licensing agency within seven days following the occurrence of such event. (E) Any unusual incident...safety of any client.

This requirement is not met as evidenced by:
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Administrator will submit incident reports and and self certify that they read and understand the regulations moving forward. Submit documents to CCLD by POC due date.
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Based on interview the licensee did not comply with the section cited above in by reporting C1's recent hospitalizations which poses a potential health and safety risk to persons in care.
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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:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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