<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600552
Report Date: 11/26/2024
Date Signed: 11/26/2024 05:05:51 PM

Document Has Been Signed on 11/26/2024 05:05 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ST. MARY'S HOMEFACILITY NUMBER:
015600552
ADMINISTRATOR/
DIRECTOR:		BOLLOSO, JOVITAFACILITY TYPE:
735
ADDRESS:34921 PERRY ROADTELEPHONE:
(510) 429-1584
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Jovita Bolloso, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:25 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 11/26/2024 at 2:10 PM Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Care Staff, Georgia De Jesus, who phoned the Administrator, Jovita Bolloso, the purpose of our visit. The Administrator arrived to the facility shortly after. The facility’s fire clearance was approved for all six (6) ambulatory only.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. There are no bodies of water. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's and linen supplies was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply. Outdoor activity space was observed furnished with tables, chairs and shade.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/03/2023. First aid kit was observed to be complete. Emergency Disaster Drill was last posted on 05/15/2024. Fire Drill was last conducted on 11/03/2024.

At 2:19 PM, 5 of 5 clients records were reviewed. At 2:45 PM, 3 staff records were reviewed, 3 of 3 has First Aid Certification and 3 of 3 associated to the facility. At 3:45 PM, LPAs reviewed client's P&I money with log and there was no discrepancies observed. At 4:15PM, LPAs reviewed 3 of client's medications.

Continue to LIC809C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ST. MARY'S HOME
FACILITY NUMBER: 015600552
VISIT DATE: 11/26/2024
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
26
27
28
29
30
31
32
Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 12/06/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan
Liability Insurance
Drivers License, Car Registration/ Insurance


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights, LIC 421FC, LIC 809-D, and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/26/2024 05:05 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/26/2024 at 04:39 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 Ajax, a cleaning chemical, knives, scissors, medication, and tools left unlocked and accessible to clients which poses an immediate health and safety rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
1
2
3
4
Administrator will provide CCLD will self certify with a statement of understanding the regulation signed and dated sent to CCLD by POC date. Administrator locked the items and made it inaccessible from clients during the visit.
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 128 degrees Fahrenheit which poses an immediate health and safety rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
1
2
3
4
Administrator will provide CCLD will self certify with a statement of understanding the regulation signed and dated and send a proof of photo to CCLD of the water temperature fixed by POC date.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/26/2024 05:05 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/26/2024 at 04:43 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(c)
(c) The amount of the bond shall be according to the following schedule:
AMOUNT SAFEGUARDED PER MONTH BOND REQUIRED
$750 or less $1,000
$751 to $1,500 $2,000
$1,501 to $2,500 $3,000
Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the administrator did not comply with the section cited above for not having sufficient Surety Bond coverage for the total P&I facility handles at a time which poses a potential personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
1
2
3
4
Administrator agrees to review client's P&I and spend down to be within current bond range and submit proof to CCLD by POC date.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 6 of 6