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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601224
Report Date: 02/25/2023
Date Signed: 02/25/2023 03:21:15 PM

Document Has Been Signed on 02/25/2023 03:21 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:ESCUETA CARE HOME #2FACILITY NUMBER:
015601224
ADMINISTRATOR:MILANETTE ESCUETAFACILITY TYPE:
740
ADDRESS:1889 WEST STREETTELEPHONE:
(510) 940-8652
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: DATE:
02/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Reynaldo Villaruel/Staff and
Kristine Marie Reta/Assistant Administrator		TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Reynaldo Villaruel, and informed the purpose of visit. LPA called and spoke with Milanette Escueta, licensee-administrator. Licensee authorized Villaruel to be with LPA during inspection as she can not come to the facility. Kristine Marie Reta, assistant administrator, arrived after about 40 minutes.

Facility has an approved LIC808 Mitigation Plan. The LIC9282 Infection Control Plan has not been submitted.

LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, hallways, residents bedrooms, staff room. laundry area, office. front and side yard. 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, disposable gloves. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Supplies of PPEs checked. Facility has antigen test kits readily available. COVID-19 signages were observed in some areas of the facility. Bathroom lavatory was observed with liquid soap and paper towel for hand drying. Trash bins were observed with touch free lids. Central storage for medications was observed locked.

Fire extinguisher checked, and observed fully charge with tag showed serviced March 30, 2022. Hot water temperature in the common bathroom was tested and measured at 120 degrees Fahrenheit.

.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2023
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: ESCUETA CARE HOME #2
FACILITY NUMBER: 015601224
VISIT DATE: 02/25/2023
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LPA observed the following:
1. Lock of storage for cleaning supplies broken.
2. Expired Almond milk, cheese and tapioca pudding (with mold).
3. No Covid-19 signages in the living room.
4. Supplies of PPES on hand not sufficient for 30 days for 5 staff: 100 disposable gloves; 135 disposable gowns; 50 surgical masks

LPA reminded Kristine Reta that the staff's N95 Fit testing certificate will be a year old by March 13. 2023. Once renewed, to submit copy to LPA.

Licensee-administrator to submit the following by March 10, 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. LIC9282 Infection Control Plan

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with licensee-administrator over the phone and with assistant administrator.

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

DATE: 02/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2023 03:21 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/25/2023 at 02:48 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: ESCUETA CARE HOME #2
FACILITY NUMBER: 015601224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 for broken storage lock which poses immediate safety risks to persons in care.
POC Due Date: 02/26/2023
Plan of Correction
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Administrator to have a new lock installed and submit picture by 2/26/23.
Type A
Section Cited
CCR
87555(a)
87555 General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 for expired food items which pose immediate health and personal rights risks to persons in care.
POC Due Date: 02/26/2023
Plan of Correction
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Staff threw the expired items while LPA was at the facility.
In addition, administrator will in-service the staff and submot copy of training topic with attendees signature by 2/26/23.
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: 02/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2023


LIC809 (FAS) - (06/04)
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