015600507-1-7-2025-15-AS-KNGN-DCPTKD-20250107134746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600507
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:47:55 PM

Document Has Been Signed on 01/07/2025 01:47 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:	C & R HOME FOR THE ELDERLY		FACILITY NUMBER:	015600507
ADMINISTRATOR/ DIRECTOR:	TEOFILO CRIS SANQUE		FACILITY TYPE:	740
ADDRESS:	34819 CLOVER STREET		TELEPHONE:	(510) 324-0627
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Precilla San Miguel, Administrator-Licensee		TIME VISIT/ INSPECTION COMPLETED:	02:15 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 this day, January 7, 2025, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection. LPA met with licensee-administrator, Precilla San Miguel, licensee-administrator and explained the purpose of the visit. LPA toured the facility inside out with Precilla. LPA inspected the kitchen, dining area, activity/game room, bedrooms, bathrooms, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the bathrooms was tested and measured at 118 degrees Fahrenheit. Fire Drill last conducted 2/20/24. Fire Extinguisher observed fully charge dated 1/30/24. LPA reviewed 3 staff and 5 residents records and interviewed 2 staff and 4 residents. 3 out of 3 staff have CPR and TB on files. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored and Medication Records. Facility does not handle residents' cash resources. LPA observed the following: -at 10:11 a.m. central storage for medications unlocked. -at 10:40 a.m. residents' medications in unlocked kitchen cabinet. -at 10:44 a.m. unlocked refrigerator with residents' medications. -at 10:50 a.m. observed knife in a cabinet unlocked. ..continued on 809C

Bennett Fong	TELEPHONE: (510) 725-7919
Kelly Nguyen	TELEPHONE: (510) 915-8702
	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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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Document Has Been Signed on 01/07/2025 01:47 PM - It Cannot Be Edited

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: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 knife in a cabinet unlocked, razor and chemical left in the resident bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/07/2025
	Plan of Correction
1 2 3 4	Staff locked knive, razor, and lock chemical during inspection. Defiency Clear.

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation central storage for medications unlocked, residents' medications in unlocked kitchen cabinet, and unlocked refrigerator with residents' medications the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/07/2025
	Plan of Correction
1 2 3 4	Staff locked medication cabinet, and lock medication in the refrigerator during inspection. Defiency Clear.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bennett Fong	TELEPHONE: (510) 725-7919
Kelly Nguyen	TELEPHONE: (510) 915-8702
	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
	VISIT DATE: 01/07/2025

NARRATIVE

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..continued on 809C

-at 10:53 a.m. peritoneal cleanser in one of the resident's bedrooms.

-at 11:01 a.m. razor and ointment in the common bathroom.

Administrator to submit the following updated/current documents by February 28, 2025:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate
5. R2 sign documents

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month. *

Exit interview conducted. A copy of the LIC421FC, this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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