015600756-8-1-2022-15-AS-ADEO-CGW24U-20220801170432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600756
Report Date: 08/01/2022
Date Signed: 08/01/2022 05:08:56 PM

Document Has Been Signed on 08/01/2022 05:08 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:	ROYAL COLONY VIEW PLACE		FACILITY NUMBER:	015600756
ADMINISTRATOR:	JULIANA TABURAZA		FACILITY TYPE:	740
ADDRESS:	2767 COLONY VIEW PLACE		TELEPHONE:	(510) 889-1288
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	8	CENSUS: 5	DATE:	08/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Sheilha Muniz/Assistant Adiministrator		TIME COMPLETED:	05:10 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	Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with staff, Leticia Iroy, and informed the purpose of LPA's visit. LPA also met with other staff, Dioscoro Iroy and Rudy Walter Soriano. LPA called Juliana Taburaza, administrato; no answer. LPA also called and sent text message to Sheilha Muniz who arrived after about fourty minutes. Facility has LIC808 Mitigation Plan on file. LPA received copy of Infection Control Plan submitted by Juliana Taburaza on June 30, 2022. Staff were fit tested for N95 respirators on August 24, 2021. Sheilha Muniz stated she'll have the staff retested; copies of certificates to be submitted by August 24, 2022. LPA toured the facility inside out with Leticia Iroy. LPA inspected the living room, dining area, kitchen, bedrooms, bathrooms, laundry area, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. LPA observed screening station located near the entrance with visitor's log, hand sanitizer and thermometer. Hand sanitizer, surgical masks and disposable gloves are readily available at the screening station. Temperature and symptoms check are done at entry for visitors and staff. Visitors are checked for proof of vaccination, and antigen test kits are readily available. Residents and staff are screened for COVID-19 symptoms and temperature is checked and recorded daily. COVID-19 signages were observed posted all throughout the facility. Supplies of PPEs were checked. Hot water temperature at one of the common bathrooms was tested and measured at 115.7 degrees Fahrenheit. Fire extinguishers checked and observed fully charge with tags showed serviced October 21, 2021. . ......continued next page

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

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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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: 08/01/2022

NARRATIVE

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At 2:41 pm, LPA observed Awesome all purpose degreaser and Comet in unlocked cabinet under the kitchen sink. LPA also observed two container of liquid laundry soap under the dining table.

The following documents to be submitted August 15, 2021:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan
4. Proof of $3M liability insurance

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 violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Sheila Muniz.

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/01/2022 05:08 PM - It Cannot Be Edited

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: 08/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants 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 for Awesome all purpose degreaser and Comet in unlocked kirchen cabinet. LPA also observed laundry soap under the dining table which pose immediate health and safety ricks to persons in care.
	POC Due Date: 08/02/2022
	Plan of Correction
1 2 3 4	Staff locked the cabinet and laundry soap were locked in the garage while LPA was at the facility. In addition, administrator to in-service the staff. Proof to be submitted by 8/02/2022.

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

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