015601167-2-20-2025-15-AS-ADEO-DE43VY-20250220173556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601167
Report Date: 02/20/2025
Date Signed: 02/20/2025 05:36:06 PM

Document Has Been Signed on 02/20/2025 05:36 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/ DIRECTOR:	JULIANA TABURAZA		FACILITY TYPE:	740
ADDRESS:	550 DEAN STREET		TELEPHONE:	(510) 538-7428
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY: 15	TOTAL ENROLLED CHILDREN: 0	CENSUS: 9	DATE:	02/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:30 PM
MET WITH:	Sheilha Muniz/Business Office Manager and Juliana Taburaza/Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:40 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	On this day, February 20, 2025, at 3:30 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Sheilha Muniz, business office manager(BOM), and Juliana Taburaza, administrator (ADM), and informed the reason for visit. LPA toured the facility inside out with BOM. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side yard and backyard. 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 in operating condition. Hot water temperature in one of the bathrooms was tested. Fire extinguishers were observed fully charge with tags showed serviced 10/10/24. Facility conducts fire and earthquake drills every quarter and records showed last conducted 2/01/25 and 2/02/25 respectively. Administrator to submit copies of the following updated/current documents by March 6, 2025: 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 ...continued on 809C

Bennett Fong	TELEPHONE: (510) 622-2621
Alicia Delmundo	TELEPHONE: (510) 286-4201
	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

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: 02/20/2025

NARRATIVE

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LPA observed the following:
-at 3:54 pm, water temperature at 101.4 degrees Fahrenheit.
-at 4:02 pm, metal grill and broken skeletal wood structure in the backyard.
-at 4:06 pm, broken mirror, metal grill, rotten shelf, pieces of bricks, broken wood pallets, rusty shopping cart, broken and dusty empty water bottles, broken wood dumpster in the side yard.
-at 4:15 pm, exposed electrical wiring in the ceiling in the kitchen.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. 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.

Deficiencies and plan and proof of correction were discussed with ADM and BOM.

Due to time constraint, LPA will come back to continue the inspection.

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: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/20/2025 05:36 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 in hot water at 101.4 degrees Fahrenheit which poses a potential health and/or personal rights risk to persons in care.
	POC Due Date: 03/06/2025
	Plan of Correction
1 2 3 4	Administrator to have the temperature adjusted within Regulations range and submit proof by 3/06/25.

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the following which pose a potential safety and/or personal rights risk to persons in care: metal grill and broken skeletal wood structure in the backyard; broken mirror, metal grill, rotten shelf, pieces of bricks, broken wood pallets, rusty shopping cart, broken and dusty empty water bottles, broken wood dumpster in the side yard; exposed electrical wiring in the ceiling in the kitchen.
	POC Due Date: 03/06/2025
	Plan of Correction
1 2 3 4	Administrator stated she'll have the following done. 1. Clean the yard. 2. Put safety cover on the electrical wiring. Pictures to be submitted by 3/06/25

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bennett Fong	TELEPHONE: (510) 622-2621
Alicia Delmundo	TELEPHONE: (510) 286-4201
	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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