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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600562
Report Date: 04/13/2023
Date Signed: 04/13/2023 07:04:37 PM

Document Has Been Signed on 04/13/2023 07:04 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:MORNING SUN CARE HOMEFACILITY NUMBER:
015600562
ADMINISTRATOR:GALANG, ROSARIOFACILITY TYPE:
735
ADDRESS:1502 171ST STREETTELEPHONE:
(510) 481-9708
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 5DATE:
04/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Maria Theresa "Tek" Ordiniza/Assistant AdministratorTIME COMPLETED:
07:05 PM
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On 04/13/2023 at 4:40 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Death Report submitted by the facility to the Department. LPA met with staff, Rolando Galang and Marieta Balilo. LPA called and spoke over the phone with Maria Theresa "Tek" Ordiniza, assistant administrator, who arrived after several minutes. LPA informed the reason for visit.

Death Report indicated that on 04/10/2023 at a little over 4:00 am, staff saw resident (R1) walking around his room and seemed restless. Staff asked R1 and R1 tried to answer but seemed like R1 was having hard time breathing. Staff called 911 right away. R1 was taken to the hospital where R1 passed away. Report indicated the per attending nurse, R1 passed away of cardiac arrest.

LPA conducted interviews, and reviewed R1's records. LPA also reviewed doctor's order of medications and remaining medications on facility's hand and compared with Medication Administration Records. LPA obtained copies of the following documents
1. LIC601 Identification and Emergency Information
2. Most current Physician's Report
3. Most current Individual Program Plan
4. Record of Medical and Dental Care
5. Medication Administration Record
6. Behavior Tracking Log

No deficiency cited on this day.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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