015601469-7-28-2021-15-AS-ADEO-C5CRAP-20210728125128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601469
Report Date: 07/28/2021
Date Signed: 07/28/2021 12:51:44 PM

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:	LOVING HOME CARE		FACILITY NUMBER:	015601469
ADMINISTRATOR:	GOLDASSIO, STEPHANIE		FACILITY TYPE:	740
ADDRESS:	22270 PERALTA STREET		TELEPHONE:	(510) 582-8839
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	5	CENSUS: 4	DATE:	07/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Matilde Miguel Machado/Licensee and Robert Goldassio/Operations Manager		TIME COMPLETED:	01:00 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 Analysts (LPAs) Alicia Delmundo and Catherine Lin arrived unannounced to conduct an annual required/infection control inspection. LPA met with Matilde Miguel Machado, licensee, and Robert Goldassio, operations manager, and informed the purpose of LPAs' visit. LPAs toured the facility inside and out with Matile and Robert. LPAs inspected the living room, dining area, kitchen, resident rooms, bathroom, side yard and backyard. Medications are centrally stored in a locked area that is inaccessible to residents and refilled every 2 weeks and 30 days. LPA observed food supplies for 2 days of perishables and 7 days non-perishables. LPAs observed COVID-19 signage. Staff checked LPAs' temperatures upon entry. Facility has hand sanitizer, masks and gloves available for visitors located inside by the entrance door. Facility has visitor's log. Personal protective equipments (PPEs) inspected. Facility has a copy of approved LIC808 Mitigation Plan and record of staff's N95 fit testing on file. Hot water temperature in one of the bathrooms was tested and measured at 108.2 degrees Fahrenheit. Fire extinguishers checked, observed fully charge with tags showed serviced July 1, 2021. LPAs received a copy of proof of $3M liability insurance coverage .....continued next page (809C)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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 4

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: LOVING HOME CARE	FACILITY NUMBER: 015601469
	VISIT DATE: 07/28/2021

NARRATIVE

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LPAs observed the following:
1. Backyard: storage for tools and automotive located in the backyard unlocked; shovel; garden shears; bleach
2. Supplies of N95 respirators and disposable gowns not sufficient for 30 days.
3. Trash bins with no lids.
4. No cough/sneeze etiquette posters in the bedrooms.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Any repeat violations within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Matilde Miguel Machado and
Robert Goldassio.

Exit interview conducted. Appeal Rights 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: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: LOVING HOME CARE	FACILITY NUMBER: 015601469
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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. LPAs observed the following in the backyard whch pose an immediate health and safety risks to persons in care: storage for tools and automotive unlocked; shovel; garden shears; bleach
	POC Due Date: 07/29/2021
	Plan of Correction
1 2 3 4	Corrected. Operations manager locked all the items and the storage.

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: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4