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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600756
Report Date: 07/21/2021
Date Signed: 07/21/2021 01:24:01 PM

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:ROYAL COLONY VIEW PLACEFACILITY NUMBER:
015600756
ADMINISTRATOR:JULIANA TABURAZAFACILITY TYPE:
740
ADDRESS:2767 COLONY VIEW PLACETELEPHONE:
(510) 889-1288
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:8CENSUS: 5DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff Leticia Iroy and Dioscoro IroyTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required/infection control inspection. LPA met with staff, Leticia Iroy and Dioscoro Iroy, and informed the purpose of LPA's visit. LPA called and spoke with Juliana Taburaza, administrator. Juliana Taburaza authorized Leticia Iroy to be with LPA during inspection and receive this report.

LPA toured the facility inside and out with Leticia Iroy. LPA inspected the living room, dining area, kitchen, resident rooms, bathrooms, side yard and backyard. Medications are centrally stored in a locked area that is inaccessible to residents and refilled every 30 days. LPA observed food supplies for 2 days of perishables and 7 days of non-perishables,

LPA observed COVID-19 signage all throughout the facility. Facility has hand sanitizer, masks and gloves available for visitors located inside near visitor's entrance door. Facility has visitor's log. Personal protective equipments (PPEs) inspected. Facility has a copy of approved LIC808 Mitigation Plan on file.

Hot water temperature in one of the bathrooms was tested and measured at 115.5 degrees Fahrenheit. Facility has working smoke and carbon monoxide detectors. Fire extinguishers checked, observed fully charge with tags showed serviced October 19, 2020.

Administrator to submit the following updated documents by August 4, 2021:
1. Proof of $3M liability insurance coverage
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan
4. Copy of surety bond coverage

......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROYAL COLONY VIEW PLACE
FACILITY NUMBER: 015600756
VISIT DATE: 07/21/2021
NARRATIVE
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LPA observed the following:
1. Exit door in the kitchen with no auditory signal and front door signal not working.
2. When asked, staff (S1) didn't know about screening of visitors prior to allowing entry. This was discussed by LPA at 10:35 am over the phone with Juliana Taburaza.
3. Insufficient supplies of N95 respirators and disposable gowns.
4. No record of staff's N95 respirator fit testing.
5. Trash bins in the bathrooms without lids.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date, and any repeat violations within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Juliana Taburaza over the phone in the presence of Leticia Iroy.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Leticia Iroy.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: ROYAL COLONY VIEW PLACE
FACILITY NUMBER: 015600756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed exit door with no auditory signal and entrance's door signal not working when review of R1's record revealed R1 has wandering behavior. These pose an immediate health and safety risks to person in care.
POC Due Date: 07/22/2021
Plan of Correction
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Administrator to have a working auditory signals installed and submit pictures by 7/22/2021.
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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6