015601483-8-8-2022-15-AS-ADEO-CH4VPY-20220808163731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601483
Report Date: 08/08/2022
Date Signed: 08/08/2022 04:40:01 PM

Document Has Been Signed on 08/08/2022 04:40 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:	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:	08/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Justino Balintona/Licensee-administrator		TIME COMPLETED:	04:30 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 annual/infection control annual inspection. LPA met with staff, Corazon Mariano and Warlita Romero. LPA called and spoke over the phone with Justino Balintona, licensee-administrator, and informed the purpose of visit. Justino arrived after several minutes. Facility has LIC808 Mitigation Plan on file. LPA started inspection with Warlita, and continued with Justino. LPA inspected the living room, dining area, kitchen, bed rooms, bathroom, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch thermometer. Surgical masks and disposable gloves are readily available at the screening station. Visitor's temperature and symptom checks are done at the entrance. Staff are screened for COVID-19 symptoms and temperature is checked and recorded daily. Antigen test kits are readily available. COVID-19 signages were observed posted all throughout the facility. All trash bins were observed with touch free/foot pedal operated lids Supplies of PPEs were checked. All staff were fit tested for N95 respirators on July 23, 2021. LPA discussed the requirement for yearly N95 fit testing Licensee stated he'll re-fit test the staff. ......continued next page

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

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: 08/08/2022

NARRATIVE

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Hot water temperature at the common bathroom was tested and measured at 114,7 degrees Fahrenheit. Fire extinguishers checked, observed fully charge and receipt showed purchased May 31, 2022. Smoke and carbon monoxide detectors were tested and observed operational. .

At 12:50 pm, LPA observed bleach, Great Value All Purpose Cleaner with Bleach, Comet and ant & roach killer in unlocked kitchen cabinet.

Licensee to submit the following updated documents by August 22, 2022:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan
4. Updated N95 fit testing record
5. Infection Control Plan

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 violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed.

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: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2022 04:40 PM - It Cannot Be Edited

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: 08/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 for bleach, Great Value All Purpose Cleaner with Bleach, ant & roach killer and Comet in unlocked kirchen cabinet which pose immediate safety risks to persons in care.
	POC Due Date: 08/09/2022
	Plan of Correction
1 2 3 4	Licensee locked the cabinet while LPA was at the facility. In addition, licensee to in-service the staff and submit copy of in-service training with attendees signatures by 8/09/2022.

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: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

LIC809 (FAS) - (06/04)

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