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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600562
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:54:12 PM

Document Has Been Signed on 09/12/2024 03:54 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/
DIRECTOR:		GALANG, ROSARIOFACILITY TYPE:
735
ADDRESS:1502 171ST STREETTELEPHONE:
(510) 481-9708
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Maria Theresa "Tek" Ordiniza/Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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At 11:35 am on this day, September 12, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Lourdita Balba. LPA also met with other staff, Marieta Balilo, and informed the purpose of visit. LPA called and spoke with
Maria Theresa "Tek" Ordiniza, assistant administrator (ADM), who gave permission to Marieta Balilo to be with LPA in touring the facility. There were 3 residents present when LPA arrived. ADM arrived at around 12:20 pm.

Facility has Infection Control Plan that was submitted and received by LPA on June 30, 2022.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining and living areas, garage, side yard and backyard. There is a supply of 7 days of non-perishable and 2 days of perishable foods. Central storage for medications was observed locked.

Fire extinguisher was observed fully charge with tag showed serviced March 19, 2024. Facility has carbon monoxide and smoke detectors that were tested and observed in operating condition. Hot water temperature in the common bathroom was tested and measured at 119.8 degrees Fahrenheit. Facility conducts disaster drills at least every quarter and records showed last conducted September 2, 2024.

LPA reviewed 5 residents and 5 staff files, and interviewed 2 residents and 2 staff. Medications were inspected and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. P&I/cash resource checked and compared with last recorded balance.


.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 5
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: MORNING SUN CARE HOME
FACILITY NUMBER: 015600562
VISIT DATE: 09/12/2024
NARRATIVE
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LPA observed the following:
-at 11:40 am, resident's (R2) toenails overgrown and discolored. According to ADM, R2 had podiatrist appointment on 5/2024 but R2 left on the day of appointment. Staff had not set-up an appointment since then.
-at 11:50 am, lancets in one of the resident' rooms.
-at 11:58 am, medications in unlocked staff room.
-at 12:03 pm, mildew/mold in the shower area and paper towel holder and missing shower tiles in one of the common bathrooms.
-at 2:00 pm, staff (S3) First Aid certificate expired 8/05/24.

LPA received copies of updated/current of following documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections (POCs) by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with ADM.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/12/2024 03:54 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/12/2024 at 03:30 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: MORNING SUN CARE HOME
FACILITY NUMBER: 015600562

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

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
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2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risks to persons in care: lancets in one of the residents' rooms and medications in unlocked staff room.
POC Due Date: 09/14/2024
Plan of Correction
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2
3
4
Staff locked the item and locked the staff room.
In addition, administrator to in-service the staff and submit proof by 9/13/24.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/12/2024 03:54 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/12/2024 at 03:30 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: MORNING SUN CARE HOME
FACILITY NUMBER: 015600562

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

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
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2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health and/or personal rights risks to persons in care: mildew/mold in the shower area and paper towel holder and missing shower tiles in one of the common bathrooms.
POC Due Date: 09/26/2024
Plan of Correction
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Administrator to do the following and submit pictures by 9/26/24:
1. Have the bathroom cleaned.
2. Have tiles installed.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in S3's expired First Aid certificate which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Administrator to have S3 register for training and submit copy of certificate by 9/26/24.
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: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/12/2024 03:54 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/12/2024 at 03:30 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: MORNING SUN CARE HOME
FACILITY NUMBER: 015600562

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(a)
Health-Related Services
(a) The licensee shall ensure that each client receives first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation, interview and record review, the licensee did not comply with the section cited above in R2's toenails overgrown and discolored and staff has not set-up an appointment for several months which poses a potential health risk to person in care.
POC Due Date: 09/26/2024
Plan of Correction
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Administrator to set-up an appointment and ensure R2 is seen. Proof to be submitted by 9/26/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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