015601483-7-13-2021-15-AS-ADEO-C4W4JR-20210713190911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601483
Report Date: 07/13/2021
Date Signed: 07/13/2021 07:09:20 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 HOME		FACILITY NUMBER:	015601483
ADMINISTRATOR:	BALINTONA, JUSTINO		FACILITY TYPE:	740
ADDRESS:	1626 ASHBURY LANE		TELEPHONE:	(510) 265-0818
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	6	CENSUS: 6	DATE:	07/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	04:10 PM
MET WITH:	Justino Balintona/Licensee-Administrator		TIME COMPLETED:	07:10 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 Analyst LPA) Delmundo arrived unannounced to conduct an annual required/infection control inspection. LPA met with Justino Balintona, licensee-administrator, and informed the purpose of LPA's visit. LPA also met with staff, Warlita Romero and Corazon Mariano. LPA toured the facility inside and out with Justino Balintona. LPA inspected the living room, dining area, kitchen, resident rooms, bathrooms, side yard and backyard. Medications are centrally stored in a locked area that is inaccessible to residents and refilled every 30, 60 and 90 days. Perishable and non-perishable food supplies were observed sufficient. LPA observed COVID-19 signage all throughout the facility. Staff checked LPA's temperature upon entry. Facility has hand sanitizer, masks and gloves available for visitors located inside by the entrance door. Facility has visitor's log. Step-on trash bins with lids observed. Personal protective equipments (PPEs) inspected. Facility has a copy of approved LIC808 Mitigation Plan on file. Hot water temperature in one of the bathrooms was tested and measured at 105 degrees Fahrenheit. Facility has working smoke and carbon monoxide detectors. Fire extinguisher checked, observed fully charge but no service tag. According to Justino, the unit was purchased March this year. LPA obtained copies of the following: 1. Copy of proof of $3M liability insurance coverage 2. Updated facility sketch 3. LIC9054 Local Fire Inspection Authority Information .....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: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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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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: ST. LOURDES HOME	FACILITY NUMBER: 015601483
	VISIT DATE: 07/13/2021

NARRATIVE

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LPA observed the following:
1. Visitor's log has no columns to record temperature and contact information.
2. No supplies of N95 respirators and disposable gowns.
3. Licensee unable to locate their supply of face shields.
4. Staff not fit tested for N95 respirators.
5. Bed frames and old mattress in the side yard.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date, and any repeat violations within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Justino Balintona.

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: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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: ST. LOURDES HOME	FACILITY NUMBER: 015601483
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2021

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed bed frames and old mattress in the side yard which pose potential safety risks to persons in care.
	POC Due Date: 07/27/2021
	Plan of Correction
1 2 3 4	Licensee to have the yard cleaned and submit picture by 7/27/2021.

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: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC809 (FAS) - (06/04)

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