015601167-2-26-2023-15-AS-ADEO-CPF3XM-20230226173833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601167
Report Date: 02/26/2023
Date Signed: 02/26/2023 05:43:38 PM

Document Has Been Signed on 02/26/2023 05:43 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:	PALM TREE COURTYARD		FACILITY NUMBER:	015601167
ADMINISTRATOR:	JULIANA TABURAZA		FACILITY TYPE:	740
ADDRESS:	550 DEAN STREET		TELEPHONE:	(510) 538-7428
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	15	CENSUS: 10	DATE:	02/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Josefino 'Budoy' Joshue and Rosalita Llegado, Staff		TIME COMPLETED:	05:50 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 annual/infection control inspection. LPA met with staff, Josefino 'Budoy' Joshue and Rosalita Llegado, and informed the purpose of visit. LPA called and spoke with Juliana Taburaza, administrator, over the phone who authorized Josefino Joshue to be with LPA during inspection, and sign and receive this report. Facility has an approved LIC808 Mitigation Plan. Administrator submitted the facility's Infection Control Plan which LPA received on June 30, 2022. LPA toured the facility inside out. LPA inspected the living room, dining area. kitchen, hallways, residents bedrooms, 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 by the front entrance with hand sanitizer, no touch temperature probe and N95 respirators. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked. Facility has antigen test kits readily available. COVID-19 signages were observed in some areas of the facility. . Bathroom lavatories were observed with liquid soap and hand dryer. Fire extinguishers checked, and observed fully charge with tags showed serviced October 18, 2022. Hot water temperature was tested in the one of the common bathrooms .......continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2023

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: PALM TREE COURTYARD	FACILITY NUMBER: 015601167
	VISIT DATE: 02/26/2023

NARRATIVE

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LPA observed the following:
1. Trash can in one of the bathrooms with no lid.
2. No "Wear Mask" posters on the front entrance door and living room.
3. Disposable gowns not sufficient for 30 days for 8 staff.
4. Hot water temperature at 100 degrees Fahrenheit.

Administrator to submit the following by March 12, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. Proof of $3M liability insurance.
5. Current N95 fit testing records/certificates

Deficiency is cited from Title 22 California Code of Regulations, and listed on 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 administrator over the phone.

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: 02/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/26/2023 05:43 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: PALM TREE COURTYARD	FACILITY NUMBER: 015601167
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for hot water at 100 degrees Fahrenheitt which poses a potential personal rights risk to persons in care.
	POC Due Date: 03/12/2023
	Plan of Correction
1 2 3 4	Staff adjusted the water temperature to 118 degrees Fahrenheit while LPA was at the facility. In addition, administrator to in-service the staff, and ensure water temperature is maintained within Regulations range. Copy of in-service training with attendees signatures to be submitted by 3/12/23.

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: 02/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2023

LIC809 (FAS) - (06/04)

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