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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601017
Report Date: 07/12/2021
Date Signed: 07/12/2021 02:44:11 PM

Document Has Been Signed on 07/12/2021 02:44 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:MISSION VILLA RESIDENTIAL CARE HOMEFACILITY NUMBER:
015601017
ADMINISTRATOR:RUBIO, MARISSAFACILITY TYPE:
740
ADDRESS:42423 PASEO PADRE PARKWAYTELEPHONE:
(510) 656-0168
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 6CENSUS: 6DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Resurreccion 'Sion' Natividad/StaffTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required/infection control inspection. LPA met with staff, Fredesvinda Farinas, Naty Domingo and Resurreccion 'Sion' Natividad, and informed the purpose of visit. LPA spoke over the phone with Marissa Rubio, licensee-administrator. Marissa can not come to the facility and authorized Resurreccion to be with LPA during inspection and receive this report.

LPA toured the facility inside out with Resurreccion Natividad. LPA inspected the living and family rooms, dining area, bathrooms, kitchen, garage, side and back yards. Food supplies were observed sufficient for 2 days of perishables and 7 days of non-perishables.

LPA observed COVID-19 signage by the dining area. Personal protective equipments (PPEs) were sufficient for 30 days. All staff were fit tested for N95 respirators. Facility has a copy of approved LIC808 Mitigation Plan on file.

Hot water temperature in one of the bathrooms was tested. Fire extinguisher checked, observed fully charge; however tag showed serviced December 26, 2019; licensee stated fire extinguisher is scheduled to be serviced. Facility has working smoke and carbon monoxide detectors.

The following documents to be submitted by July 26, 2021:
1. Copy of surety bond coverage
2. Copy of proof of $3M liability insurance coverage


.....continued next page (809C)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2021
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: MISSION VILLA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601017
VISIT DATE: 07/12/2021
NARRATIVE
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LPA observed the following:
1. Medication cabinet, cabinet where cleaning and laundry supplies were kept, and cabinet for knives were unlocked.
2. Medications in unlocked staff bedroom.
3. Trash cans without lids in bathrooms and residents' bedrooms.
4. No hand washing posters in bathrooms and kitchen
5. No visitor's poster in the entrance door
6. Although staff screened LPA's temperature, there's no central station for visitor's log, hand sanitizer and/or masks by the front door.
7. Hot water was measured at 103.5 degrees Fahrenheit.

Deficiencies is cited from Title 22 California Code of Regulations (see 809Ds). Failure to submit proof of corrections 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 correction were discussed with Marissa Rubio over the phone.

Exit interview conducted with Resurreccion Natividad. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided at the conclusion of interview.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/12/2021 02:44 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/12/2021 at 01:50 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: MISSION VILLA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) 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 above. LPA observed trash cans without lids in bathrooms and residents' bedrooms which pose a potential health and personal rights risks to persons in care.
POC Due Date: 07/26/2021
Plan of Correction
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Licensee stated she'll purchase trash bins with lids. Proof of purchase and pictures to be submitted by 7/26/2021.
Type B
Section Cited
CCR
87303(e)(2)
87303 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 degree C) and not more than 120 degree F (49 degree 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. Hot water temperature was tested and measured at 103.5 degrees Fahrenheit which poses a potential health and personal rights risks to persons in care.
POC Due Date: 07/26/2021
Plan of Correction
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Licensee to adjust and ensure the water temperature is maintained within Regulations range. Proof to be submitted by 7/26/2021.
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: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2021


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 07/12/2021 02:44 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/12/2021 at 02:05 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: MISSION VILLA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication

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. LPA observed unlocked central storage for medications which poses an immediate health risk to persons in care.
POC Due Date: 07/13/2021
Plan of Correction
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Staff locked medication.
Licensee to in-service the staff and submit proof by 7/13/2021.
Type A
Section Cited
CCR
87307(d)(3)
87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(3) All persons shall be protected against hazards within the facility through provision of the following:


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. LPA observed the following: unlocked cabinet where knives are kept; unlocked storage for laundry and cleaning supplies; medications in unlocked staff bedroom. These pose immediate health and safety risks to persons in care.
POC Due Date: 07/13/2021
Plan of Correction
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Staff locked the cabinets and staff bedroom.
Licensee to in-service the staff and submit copy of training topic with attendees signatures by 7/13/2021.
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: 07/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2021


LIC809 (FAS) - (06/04)
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