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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
015600552
Report Date:
11/28/2023
Date Signed:
11/28/2023 02:36:53 PM
Document Has Been Signed on
11/28/2023 02:36 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:
ST. MARY'S HOME
FACILITY NUMBER:
015600552
ADMINISTRATOR:
BOLLOSO, JOVITA
FACILITY TYPE:
735
ADDRESS:
34921 PERRY ROAD
TELEPHONE:
(510) 429-1584
CITY:
UNION CITY
STATE:
CA
ZIP CODE:
94587
CAPACITY:
6
CENSUS:
5
DATE:
11/28/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
Jovita Bolloso
TIME COMPLETED:
03:05 PM
NARRATIVE
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On this day at around 10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA was met by staff Lutgarda Marquez. LPA explained to Marquez the purpose of the visit. Administrator Jovita Bolloso (Admin cert#6011284735) arrived at around 10:20 am.
The facility is a Level 4C home vendorized by the Regional Center of the East Bay with an approved fire clearance for 6 ambulatory clients. During the visit, two clients were observed in the home but went out at around 11:15 am.
LPA inspected the facility inside and out including but not limited to client rooms, kitchen, dining and living areas, garage and backyard. At 10:10 am, LPA observed hot water temperature in the kitchen measured at 133 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. There was ample supply of linen, towels, and sheets available for use of clients. Fire extinguisher was observed full and was last serviced in May 2022. Smoke detectors and carbon monoxide were tested and observed functional. First aid kit was observed complete. Administrator was unable to provide proof of disaster training to LPA during the visit.
At around 10 am, LPA verified P & I money and log and observed records and money were accurate. The facility has surety bond sufficient to cover the amount of cash being handled at one time.
At 11:00 am, LPA reviewed 5 client records and 3 staff records. At 1pm, LPA interviewed staff on duty. At 2:05 pm, LPA interviewed 2 clients who came back from the day program.
Deficiencies were observed (see Lic 809D) per Title 22 California Code of Regulations.
Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/28/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2023
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
6
Document Has Been Signed on
11/28/2023 02:36 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
11/28/2023
at
01:20 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:
ST. MARY'S HOME
FACILITY NUMBER:
015600552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
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 having the former client's things such as 4 bicycles, tools, small cabinet, etc which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/29/2023
Plan of Correction
1
2
3
4
Administrator will clear side gate passageway and send photo proof to CCL.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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 having unlocked medicines in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/28/2023
Plan of Correction
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2
3
4
Administrator locked all medicines in the refrigerator during the visit.
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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2023
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
11/28/2023 02:36 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
11/28/2023
at
01:20 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:
ST. MARY'S HOME
FACILITY NUMBER:
015600552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(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 having hot water temperature at 133 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/29/2023
Plan of Correction
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2
3
4
Administrator will adjust hot water temperature and submit proof to CCL.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2023
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
11/28/2023 02:36 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
11/28/2023
at
01:20 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:
ST. MARY'S HOME
FACILITY NUMBER:
015600552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(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 having empty boxes, wooden planks, etc and broken closet sliding glass door/light switch, fire extinguisher last inspected in May 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/12/2023
Plan of Correction
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3
4
Administrator will get backyard cleaned and replace broken sliding closet door and send photo proof to CCL.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.
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 having ripped sliding screen doors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/12/2023
Plan of Correction
1
2
3
4
Administrator will replace all ripped screen doors and send photto proof to CCL.
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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2023
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
11/28/2023 02:36 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
11/28/2023
at
01:20 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:
ST. MARY'S HOME
FACILITY NUMBER:
015600552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.
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 not having a shaded area in the backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/12/2023
Plan of Correction
1
2
3
4
By POC date, Administrator will provide a shaded area for clients in the backyard and will send photo proof to CCL.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2023
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
11/28/2023 02:36 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
11/28/2023
at
02:17 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:
ST. MARY'S HOME
FACILITY NUMBER:
015600552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)(2)
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 not having updated disaster drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/12/2023
Plan of Correction
1
2
3
4
Administrator will conduct disaster drill training and submit proof to CCL.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2023
LIC809
(FAS) - (06/04)
Page:
6
of
6