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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601295
Report Date: 05/30/2024
Date Signed: 05/30/2024 06:58:09 PM

Document Has Been Signed on 05/30/2024 06:58 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 3, INC.FACILITY NUMBER:
015601295
ADMINISTRATOR/
DIRECTOR:		ESCUETA, MILANETTEFACILITY TYPE:
740
ADDRESS:23571 RONALD LANETELEPHONE:
(510) 785-0203
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 4CENSUS: 3DATE:
05/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:MIlanette Escueta/Administrator TIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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At 11:45 a.m. on this day, May 30, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Joana Tiglao. LPA also met with other staff, Ernesto Cochico Jr., Ravina Olivete and Kristine Reta. LPA called and spoke with Milanette Escueta, administrator, over the phone, and authorized Joana Tiglao to be with LPA during inspection. Administrator arrived at around 12:05 p.m.

Administrator submitted the LIC9282 Infection Control Plan which LPA received on May 16, 2023.

LPA toured the facility inside out with Joana Tiglao. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, garage, 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.

Hot water temperature in the common bathroom was tested. Fire extinguisher was observed fully charge with tag showed serviced 2/19/24. First aid kit inspected and observed complete with manual. Facility conducts fire drills monthly, and records showed last conducted 5/20/24.

LPA reviewed 5 staff and 3 residents files, and interviewed 2 staff. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Residents P&I checked and compared with last recorded balance.

LPA observed the following:
-at 11:53 a.m., scissors on the top of the shelf in the dining area.
-at 11:57 a.m., peelers in kitchen cabinets without lock.

.......continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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 3, INC.
FACILITY NUMBER: 015601295
VISIT DATE: 05/30/2024
NARRATIVE
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-at 12:00 noon, former resident's medications in unlocked garage.
-at 12:07 p.m., hot water at 103.2 degrees Fahrenheit.
-at 12:16 p.m., pieces of wood, metal grill, 2 pails of paint, Hydraulic oil, rusted cart, missing wood planks fence in the backyard.
-at 12:17 p.m., side fence's wood planks coming off.
-at 2:50 p.m., staff (S4) required 40 hours of training not completed within 4 weeks of employment.
-at 4:30 p.m., all 3 residents' LIC625 Appraisal/Needs and Services Plan are over a year old.

Administrator to submit updated/current copies of the following documents by June 13, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage
5. $3M Liability Insurance certificate

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections (POCs) 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 corrections were discussed with the 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: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/30/2024 06:58 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/30/2024 at 05:37 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 3, INC.
FACILITY NUMBER: 015601295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 out of 3 residents' LIC625 over a year old which pose a potential health risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Administrator to update the LIC625 and submit self-certifcation by 6/13/24.
Type B
Section Cited
HSC
1569.625(b)(1)
§1569.625 Staff training; legislative findings; contents: (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses..........
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 in S4’s required 40 hours of training not completed within 4 weeks of employment which posed a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Administrator to have the staff complete the training and submit self-certification by 6/13/24.
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: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/30/2024 06:58 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/30/2024 at 06:08 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 3, INC.
FACILITY NUMBER: 015601295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

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 in the following which pose an immediiate risks to the safety of persons in care: unlocked scissors; peelers in kitchen cabinet without lock; 2 pails of paint and Hydraulic oil in the backyard; former resident’s medications in unlocked garage
POC Due Date: 05/31/2024
Plan of Correction
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Staff locked the items.
In addition, admninistrator to in-service the staff and submit copy of training topics with attendees signatures by 5/31/24.
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 Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/30/2024 06:58 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/30/2024 at 06:18 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 3, INC.
FACILITY NUMBER: 015601295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

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 in the following which pose a potential safety and/or personal rights risks to persons in care: pieces of wood, metal grill, rusted cart, missing wood planks fence in the backyard; side fence's wood planks coming off.
POC Due Date: 06/13/2024
Plan of Correction
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Administrator to do the following and submit pictures by 6/13/24:
1. Have the yard cleaned.
2. Have the fence repaired.
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 in hot water at 103.2 degrees Fahrenheit.
which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Administrator to have the water temperature adjusted within Regulations range and submit proof by 6/13/24.
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: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
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