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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601483
Report Date: 03/15/2021
Date Signed: 03/15/2021 05:11:15 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:ST. LOURDES HOMEFACILITY NUMBER:
015601483
ADMINISTRATOR:BALINTONA, JUSTINOFACILITY TYPE:
740
ADDRESS:1626 ASHBURY LANETELEPHONE:
(510) 265-0818
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 5DATE:
03/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Justino Balintona/Licensee-AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Delmundo called and spoke with Justino Balitona, licensee-adminisrator to follow-up on the information LPA received. LPA informed Mr. Balintona the purpose of call.

LPA received an SOC341 on March 13, 2021. Document indicated that when staff take resident (R1) to get his medications, one of the medication has been taken. R1's family member have expressed concerns that an individual (whom R1 knows) is taking financial advantage of R1 and has attempted to become R1's caretaker.

On this day, LPA conducted interviews. LPA requested Mr. Balintona to submit the following documents by Wednesday, March 17th:
1. LIC601 Identification and Emergency Information
2, Admission Agreement
3. LIC602A Physician's Report
4. Copy of doctor's order of medications
5. House Rules

Exit interview conducted and copy of report provided via email.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
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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