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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600545
Report Date: 09/14/2022
Date Signed: 09/14/2022 07:42:57 PM

Document Has Been Signed on 09/14/2022 07:42 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:ITHACA HOMEFACILITY NUMBER:
015600545
ADMINISTRATOR:DE LEON, VICTORFACILITY TYPE:
735
ADDRESS:32295 ITHACA STREETTELEPHONE:
(510) 400-3168
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 3DATE:
09/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Florante 'Dan' Landingin/Care StaffTIME COMPLETED:
07:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management inspection in regards to Special Incident Report (SIR) submitted by the facility and forwarded to LPA on Monday, September 12, 2022. The SIR indicated that on September 9, 2022, at about 9:00 am, staff (S1) went to resident's (R1) room to check R1; R1 was observed still sleeping. At about 10:30 am, S1 went to R1's room again to check and noticed R1 not moving. S1 checked R1's pulse and felt nothing. S1 called 9-1-1 immediately and informed the administrator. First responders arrived but R1 was already deceased. .

On this day, September 14, 2022, LPA met with staff, Florante 'Dan' Landingin, care staff, and informed the reason for visit. LPA called and spoke with Imelda De Leon, licensee, over the phone and informed the purpose of call. Licensee indicated she is at her other facility and won't be able to meet LPA, and authorized Landingin, to sign and receive this report. LPA also called and spoke with Victor De Leon, administrator, over the phone.

LPA reviewed R1's file including but not limited to LIC602 Physician's Report, Individual Program Plan, Medication Administration Record (MAR) and inspected R1's medications. LPA also conducted interviews.

LPA observed the following:
1. R1 passed away in the morning of September 9, 2022 but R1's MAR showed initials of staff (S2) on September 10, 2022 and September 11, 2022. Inspection of actual medications showed remaining medications for September 9, 2022 to September 30, 2022.
2. LPA checked Community Care Licensing (CCL) Guardian Portal and LIS Facility Employee Roster which showed S2 not fingerprint cleared and associated. LPA interviewed the administrator who stated that S2 works on weekends and started working 2 months ago.

.....continued next page (809C)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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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: ITHACA HOME
FACILITY NUMBER: 015600545
VISIT DATE: 09/14/2022
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. A $500.00 civil penalty is assessed for deficiency section # 80019(e). Failure to submit proof of corrections (POCs) by plan of correction due dates may result in additional civil penalties.

Deficiencies, plan and proof of corrections, and civil penalty were discussed with Imelda De Leon and Victor De Leon over the phone.

Exit interview conducted. Appeal Rights, LIC421BG, LIC9098 Proof of Correction form and copy of this report provided to Florante Landingin.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/14/2022 07:42 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/14/2022 at 06:53 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: ITHACA HOME
FACILITY NUMBER: 015600545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2022
Section Cited
CCR
80019(e)

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80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption......
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Administrator stated he'll have the staff fingerprinted and associated. Proof to be submitted. by 09/15/2022.

A $500.00 civil penalty is assessed.
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-This requirement is not met as evidenced by:
-Based on interview and records review, the licensee did not comply with the section above for not having the staff fingerprint and associated which poses immediate safety risks to persons in care. A civil penalty is assessed.
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Type B
09/28/2022
Section Cited
CCR80070(a)

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80070 Client Records
a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

-This requirement is not met as evidenced by:
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Administrator to in-service the staff and submit copy of training with attendees signatures by 09/28/2022
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-Based on records review, the license did not comply with the section above for having incorrect MAR for R1.
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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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


LIC809 (FAS) - (06/04)
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