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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601167
Report Date: 02/01/2024
Date Signed: 02/01/2024 06:28:30 PM


Document Has Been Signed on 02/01/2024 06:28 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 COURTYARDFACILITY NUMBER:
015601167
ADMINISTRATOR:JULIANA TABURAZAFACILITY TYPE:
740
ADDRESS:550 DEAN STREETTELEPHONE:
(510) 538-7428
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:15CENSUS: 10DATE:
02/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sheilha Muniz/Business Office Manager and
Juliana Taburaza/Administrator		TIME COMPLETED:
06:30 PM
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On this day, February 1, 2024, at 11:30 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Sheilha Muniz, business office manager, and informed the reason for visit. LPA also met with other staff, Corazon Bugarin, Rosalita Llegado and Josefino Josue. Juliana Taburaza, administrator, arrived at 2:00 p.m.

Administrator submitted the LIC9282 Infection Control Plan on June 30, 2022.

LPA toured the facility inside out with the business office manager. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has smoke and carbon monoxide detectors that were tested, and observed functional. Hot water temperature in one of the bathrooms was tested, and measured at 105 degrees Fahrenheit. Fire extinguisher was observed fully charge with tag showed serviced 10/23/23. Facility conducts disaster drills monthly, and records showed last conducted 1/02/24.

LPA reviewed 5 residents and 5 staff files, and interviewed 3 staff and 3 residents. Medications were checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Residents' P&Is were checked and compared with records.


...continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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 3


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: 02/01/2024
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LPA observed the following:
-at 5:25 p.m., resident (R3) has 2 orders for Ferrous Sulfate on same date - one was 1 tab 1x daily and 1 tab 2x daily. Label for this medication at facility's hand showed 1 tab daily or as directed, and facility administers once daily.

Administrator to submit copies of the following updated/current documents by February 15, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate
5. Proof of Surety Bond coverage

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 penalties.

Deficiency and plan and proof of correction were discussed with the administrator and business office manager.

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

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/01/2024 06:28 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: 02/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for R3 having 2 orders for Ferrous Sulfate and facility administers only once which poses an immediate health, and/or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Administrator to check with the doctor if the medication is to be administered once or twice daily. Proof to be submitted by 2/02/24.
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: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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