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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600563
Report Date: 08/07/2024
Date Signed: 08/07/2024 02:21:38 PM

Document Has Been Signed on 08/07/2024 02:21 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:A - R RESIDENTIAL CARE HOME FOR ELDERLY #2FACILITY NUMBER:
015600563
ADMINISTRATOR/
DIRECTOR:		BAUTISTA, ROMULO S.FACILITY TYPE:
740
ADDRESS:32322 JEAN DRIVETELEPHONE:
(510) 324-4478
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Marjulie L Aliang, Care Staff TIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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On 8/7/2024 at 9:00AM, Licensing Program Analysts (LPAs) K. Nguyen and Patricia Manalo arrived unannounced to conduct an annual inspection. LPAs met with staff, Marjulie Aliang and explained the purpose of the visit. Administrator, Alejandria Bautista is currently out of town and gave verbal permission for care staff Marjulie Aliang to sign the report.

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 8/18/23. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 98 degrees F in the hallway bathroom. LPAs observed grab bars and non-skid mat in the bathroom. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Last fire drill was conducted on 4/2/2024. Facility has a current liability insurance from 6/29/24 to 06/26/25.

LPA reviewed 6 resident and 3 staff files starting at 11:10AM. LPAs reviewed a sample of resident's medications starting at 10:45AM. LPAs interviewed 3 residents and 1 staff at 12:00PM.

Report continue on LIC 809c..
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 08/07/2024 02:21 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 08/07/2024 at 01:33 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: A - R RESIDENTIAL CARE HOME FOR ELDERLY #2
FACILITY NUMBER: 015600563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having hot water measured at 98 degrees F in the hallway bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Administrator will fix the water temperature and will submit photo to CCLD by POC date.
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in by having unlocked medications inside the resident drawer, and in resident bathroom behind the mirror, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Staff locked up the medications during inspection. Deficency Cleared
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:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2024 02:21 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 08/07/2024 at 01:33 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: A - R RESIDENTIAL CARE HOME FOR ELDERLY #2
FACILITY NUMBER: 015600563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited because there was mold in the corner of one resident's closet, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Administrator will contact professional mold inspector to ensure proper removal of mold and submit photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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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: A - R RESIDENTIAL CARE HOME FOR ELDERLY #2
FACILITY NUMBER: 015600563
VISIT DATE: 08/07/2024
NARRATIVE
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Deficiencies observed:

At 10:00AM, LPAs observed unlocked medications inside the resident drawer, and in resident bathroom behind the mirror. Staff locked up the medications during inspection.

At 10:15AM, LPAs measured hot water at 98 degrees F in the hallway bathroom.

At 10:20AM LPAs observed mold in the corner of one resident closet.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
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