Community Care Licensing

Document Has Been Signed on 04/10/2024 05:49 PM - It Cannot Be Edited

FACILITY NAME:	BESCO GARDEN		FACILITY NUMBER:	011440823
ADMINISTRATOR/ DIRECTOR:	LAGUNA, ROBERT I.		FACILITY TYPE:	735
ADDRESS:	40242 CROCKETT STREET		TELEPHONE:	(510) 226-8813
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY: 6		CENSUS: 2	DATE:	04/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:10 AM
MET WITH:	Rosario Mababa, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	06:15 PM

SUPERVISORS NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024

Link to Parent Document Below:

FACILITY NAME: BESCO GARDEN	FACILITY NUMBER: 011440823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Type A

Section Cited

CCR

80087(g)

(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 in by not having Lysol Disinfectant, Mop Shine, Favor and bottled spray Fabuloso inaccessible to clients which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Administrator will read the regulation and self-certify that they read and understand the regulation moving forward. Submit a copy to CCLD by POC due date. Caregiver removed and locked the items during visit.

Type A

Section Cited

CCR

80088(e)(1)

(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 by not having water temp in shared bathroom bwtn 105-120 F which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Administrator will read the regulation and self-certify that they read and understand the regulation moving forward. Submit photos to CCLD by POC due date showing that water temp in bathroom is at the required levels.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024

Link to Parent Document Below:

FACILITY NAME: BESCO GARDEN	FACILITY NUMBER: 011440823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Type A

Section Cited

CCR

85076(d)(1)

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by having 1 week non-perishable (canned foods/emergency/water) and 2 days fresh perishable foods (fruits/vegetables) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Administrator will purchase groceries and provide a copy of receipt and photos of all foods purchase by sending to CCLD by POC due date

Type A

Section Cited

CCR

80020(a)

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. 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 by having the "Staff Room" door boarded up which was not originally approved by the fire department which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Administrator will remove the wood that is covering the outside door and send a photo to CCLD within 24hrs. Administrator will submit a new facility sketch and LIC 200 to CCLD for a new fire inspection

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024

Link to Parent Document Below:

FACILITY NAME: BESCO GARDEN	FACILITY NUMBER: 011440823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Type B

Section Cited

CCR

80087(a)

(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 in by having ladder. mattress, expired extinguisher, rocking chair, blender, all old items in shed removed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2024
	Plan of Correction
1 2 3 4	Administrator agree to clean back yard, remove items from shed and send photos to CCLD by POC due date.

Type B

Section Cited

CCR

80020(c)

(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the licensee did not comply with the section cited above in by not conducting fire/earthquake drills quarterly which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	Administrator will self-certify that they read and understand the regulation moving forward and send copy to CCLD by POC due date. In addition, Administrator agree to conduct the drills stated above and send a list of all participants to CCLD by POC due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024

Link to Parent Document Below:

FACILITY NAME: BESCO GARDEN	FACILITY NUMBER: 011440823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Type B

Section Cited

CCR

80066(a)(10)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by having a Health Screening for S1 and S2 on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2024
	Plan of Correction
1 2 3 4	Administrator agree to send a copy of Health Screening to CCLD by POC due date.

Type B

Section Cited

CCR

80066(a)(11)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having a negative TB result for S2 which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/08/2024
	Plan of Correction
1 2 3 4	Administrator agree to send a copy of negative TB result for S2 to CCLD by POC due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024

Link to Parent Document Below:

FACILITY NAME: BESCO GARDEN	FACILITY NUMBER: 011440823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Type B

Section Cited

CCR

80075(f)

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having valid First Aid certifications for S1 and S2 on file which poses a potential health and safety risk to persons in care.
	POC Due Date: 05/08/2024
	Plan of Correction
1 2 3 4	Administrator agree to send First Aid certifications to CCLD by pOC due date.

Type B

Section Cited

CCR

80076(a)(1)

(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner. 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 by not having a selection of good quality/quantity of foods/snacks for clients which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	Administrator will submit a menu of food prepared and send a copy of menu of foods that clients want to eat. In addition, administrator will throw out all expired can and other foods from cabinets. Send a copy of updated menu and photo of foods prepared for the clients preference to CCLD by POC due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024

Link to Parent Document Below:

FACILITY NAME: BESCO GARDEN	FACILITY NUMBER: 011440823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Type B

Section Cited

HSC

1565(d)

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having an updated and signed Emergency Disater Plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	Administrator will submit an updated and signed Emergency Disaster Plan to CCLD by POC due date.

Type B

Section Cited

CCR

80075(e)(2)(A)(B)

(e) In adult CCFs, when a client requires oxygen the licensee is responsible for the following: (2) Ensuring that the following conditions are met if oxygen equipment is in use: (A) The licensee makes a written report to the local fire jurisdiction that oxygen is in use at the facility. (B) "No Smoking - Oxygen in Use" signs shall be posted in appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in by not sending a written report to local fire jurisdiction and having a No Smoking Sign on Bedroom #3 which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	Administrator will send copy a letter to local fire jurisdiction notifying of oxygen in use and place "No Smoking-Oxygen In Use" signage on Bedroom #3 where oxygen is currently in use.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024

Link to Parent Document Below:

FACILITY NAME: BESCO GARDEN	FACILITY NUMBER: 011440823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Type B

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 by having expired fire extinguisher tagged which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	Administrator will replace fire extinguisher or have appropriate fire company to tag extinguisher(s) with current tags. Will send a copy of receipt and photo of new tagged fire extinguisher to CCLD by POC due date.

Type B

Section Cited

CCR

87468(c)(2)(A)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. 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 having the PUB 475 in the size 20” x 26” which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2024
	Plan of Correction
1 2 3 4	Administrator will place PUB 475 in the size 20"x26" in entry way and send a photo of poster to CCLD by POC due dtae.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024

Link to Parent Document Below:

FACILITY NAME: BESCO GARDEN	FACILITY NUMBER: 011440823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Type B

Section Cited

CCR

85068.4(g)

(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by having an approved age exception on file for C1 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2024
	Plan of Correction
1 2 3 4	Administrator will submit an exception request for C1 and submit all supporting documents to CCLD by POC due date.

Type B

Section Cited

CCR

85064(e)(f)

(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. (f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable of, and responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above in by being at the facility for required hours which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2024
	Plan of Correction
1 2 3 4	Administrator will self-certify that they read and understand the regulation moving forward and submit an updated LIC 500 of required scheduled hours that they are at the facility to CCLD by POC due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024

FACILITY NAME: BESCO GARDEN	FACILITY NUMBER: 011440823
	VISIT DATE: 04/10/2024