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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601483
Report Date: 02/28/2025
Date Signed: 02/28/2025 01:03:40 PM

Document Has Been Signed on 02/28/2025 01:03 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 HOMEFACILITY NUMBER:
015601483
ADMINISTRATOR/
DIRECTOR:		BALINTONA, JUSTINOFACILITY TYPE:
740
ADDRESS:1626 ASHBURY LANETELEPHONE:
(510) 265-0818
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Justino Balintona/Licensee-Administrator TIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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On this day, 2/28/25, at 11:05 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) for resident (R1) submitted by the facility and received by LPA on 2/27/25. LPA was granted entry by staff, Norma Gano. LPA called and spoke over the phone with Justino Balintona, licensee-administrator, and informed the reason for visit. Licensee arrived at around 11:35 am.

UIR indicated that on 2/27/25, the licensee noticed R1 was not in his room. The whole house was searched and the other resident's room's door leading to the outside was ajar and fence gate open. The immediate surroundings were searched and police assistance requested. R1 was located along the road 3 blocks from the facility with abrasion on the right forehead. R1 was brought to the hospital.

LPA checked and observed all exit doors have auditory signals but unarmed. LPA also observed the following: staff's (S1 and S2) medications in the living room; disinfectant spray in the dining area.

LPA met and interviewed R1. LPA observed bandage in R1's forehead and bruise in the left palm. LPA also interviewed the staff.

LPA reviewed R1's file and obtained copy of LIC602A Physician's Report and LIC601 Identification and Emergency Contact Information. LIC602A showed R1 has major neuro cognitive disease and will be at risk if R1 leaves unassisted.


.....continued on 809C
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201
DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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: 02/28/2025
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 87705(d) and $250.00 for repeat violation of section 87309(a) within 12 month period and will continue for $100.00/day for each if not corrected.

Deficiencies and plan and proof of corrections were discussed with the licensee

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and LIC421FC Civil Penalty Assessments, and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2025 01:03 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: 02/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2025
Section Cited
CCR
87705(d)

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87705 Care of Persons with Dementia
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement..
-This requirement is not met as evidenced by:
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Licensee installed auditory signals on fence gates. Licensee tumed on the auditory signals on exit doors while LPA was at the facility.
In addition, licensee to in-service the staff and submit proof by 3/01/25.
A $500.00 civil penalty is assessed.
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-Based on observation , record review and interview, the licensee did not comply in R1 able to leave unnoticed and the auditory signals of all exit doors disarmed which posed an immediate risk to the person in care. R1 sustained injuries.
Civil penalty is assessed.
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Type A
03/01/2025
Section Cited
CCR87309(a)

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87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents......
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Staff and licensee locked the items while LPA was at the facility.
In addition, licensee to in-service the staff and submit proof by 3/01/25.

A $250.00 civil penalty is assessed
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--This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above in unlocked staff medications and disinfectant spray which posed immediate risks to persons in care. This is a repeat violation
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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.
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201

DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025

LIC809 (FAS) - (06/04)
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