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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600545
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:56:15 PM

Document Has Been Signed on 01/11/2024 03:56 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:ITHACA HOMEFACILITY NUMBER:
015600545
ADMINISTRATOR:DE LEON, VICTORFACILITY TYPE:
735
ADDRESS:32295 ITHACA STREETTELEPHONE:
(510) 400-3168
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 4DATE:
01/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Victor De Leon, Licensee/AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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On 01/11/2024 at 11:10AM Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla arrived unannounced to conduct a Case Management visit. LPAs met with Caregiver, Florante "Dan" Landingin. Dan phoned Licensee/Administrator, Victor De Leon to inform. Victor arrived approximately at 11:15AM

While LPAs L. Alexander and L. Fontanilla were conducting a complaint investigation (15-AS-20240102142901) on 01/11/2024. LPAs observed the following:

At 10:53AM, medication unlocked located in refrigerator outside
At 10:54AM, scissors unlocked on counter located in kitchen
At 10:55AM, Colchicine 500 MCG Tablets unlocked laying on dining room tablet
At 11:00AM, unlocked Sulfamethoxazole E-Tm Sup prescription medication, over the-counter Acetaminophen and Gummies vitamins located in client's bedroom#3.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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 01/11/2024 03:56 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 01/11/2024 at 11:59 AM
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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2024
Section Cited
CCR
80075(k)(1)

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80075 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.
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Licensee/Administrator removed and locked up medications and scissors. Deficiency cleared.
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Based on LPAs observation licensee did not comply with the section cited above by not locking medications and sharps located in the kitchen and client's bedroom which poses an immediate health and safety risk to residents.
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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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
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