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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601483
Report Date: 08/20/2026
Date Signed: 08/20/2026 07:56:48 PM

Document Has Been Signed on 08/20/2026 07:56 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: 6CENSUS: 6DATE:
08/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Justino Balintona/Licensee-AdministratorTIME VISIT/
INSPECTION COMPLETED:
08:00 PM
NARRATIVE
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On this day, 8/20/26, at 2:30 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Justino Balintona, licensee-administrator, and informed the reason for visit. LPA also met with staff, Warlita Romero and Norma Gano.

LPA toured the facility inside out with Justino Balintona. LPA inspected the dining room, kitchen, bedrooms, bathrooms, living room, side and backyards. Food supplies were observed sufficient for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked.

Facility has smoke and carbon monoxide detectors that were tested and observed in operating condition. Hot water temperature in the common bathroom was tested, and measured at 110 degrees Fahrenheit. Facility disaster drills conducted every quarter and records showed last conducted 7/10/26.

LPA reviewed 5 residents and 5 staff files, and interviewed 2 residents. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.


...continued on 809C
Bennett Fong
Alicia Delmundo
DATE: 08/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/20/2026
NARRATIVE
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LPA observed the following:
  • at 2:50 pm, lighter and resident's medication unlocked in kitchen drawers.
  • at 2:58 pm, Ca-Rezz incontinent wash unlocked in resident's room.
  • at 3:01 pm, moldy shower room and rusty towel holder in residents' ensuite bathroom.
  • at 3:29 and 3:30 pm, smoke detectors in living room and hallway have wiring exposed due to covers were missing.
  • at 3:28 pm, cobwebs on the living room and kitchen ceiling.
  • from 3:45 pm to 4:00 pm, Staff (S2, S3, S4 and S5) do not have hospice care training on file.
  • at 4:30 pm, Resident R2's medical assessment (LIC602A) on file is over a year old. There's no doctor's order for half bed rails.
  • Residents (R1, R2, R3, R4, R5) have no LIC9172 Functional Capability Assessments on file.
  • at 5:45 pm, Resident R5's medical assessment (LIC602A) on file was dated 11/15/24.

On this day, LPA obtained copies of the following updated/current documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan
4. $3M liability insurance certificate

Deficiencies and plan and proof of corrections were discussed with the Licensee-Administrator.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/20/2026 07:56 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2026 at 06:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST. LOURDES HOME
FACILITY NUMBER: 015601483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risks to persons in care: lighter and resident's medication unlocked in kitchen drawers; Ca-Rezz incontinent wash unlocked in resident's room
POC Due Date: 08/21/2026
Plan of Correction
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Licensee locked the items.
In addition, licensee to in-service the staff and submit copy of training topics with attendees signatures by 8/21/26.
Type A
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in smoke detectors in living room and hallway have wiring exposed due to covers were missing which pose an immediate safety and/or personal rights risks to persons in care.
POC Due Date: 08/21/2026
Plan of Correction
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Licensee stated he'll have smoke detectors covered. Pictures to be submitted by 8/21/26.
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 Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2026 07:56 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2026 at 06:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST. LOURDES HOME
FACILITY NUMBER: 015601483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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
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2
3
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Based on observation, the licensee did not comply with the section cited above in rusty towel holder in residents' ensuite bathroom and cobwebs on the living room and kitchen ceiling which pose potential personal rights risks to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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Licensee stated he'll have the paper towel holder replaced.
In addition, licensee to have ceiling cleaned. Pictures to be submitted by 9/03/26.
Type B
Section Cited
CCR
87303(a)(1)
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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in moldy shower room in ensuite bathroom which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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Licensee stated he'll have the shower room/bathroom cleaned. Picture to be submitted by 9/03/26.
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 Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 08/20/2026 07:56 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2026 at 06:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST. LOURDES HOME
FACILITY NUMBER: 015601483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in Staff (S2, S3, S4 and S5) not having hospice care training on file which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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Licensee stated he'll have the staff trained. Proof to be submitted by 9/03/26.
Type B
Section Cited
CCR
87506(b)(17)(B)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 5 out of 5 residents have no LIC9172 on file which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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Licensee to complete the LIC9172 and submit copies by 9/03/26.
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 Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/20/2026 07:56 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2026 at 06:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST. LOURDES HOME
FACILITY NUMBER: 015601483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in Resident R2 and R5's medical assessment (LIC602A) on file over a year old which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 09/03/2026
Plan of Correction
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2
3
4
Licensee to have R2 and R5 scheduled for medical assessment. Copies of LIC602A to be submitted by 9/03/26.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on record review, the licensee did not comply with the section cited above in not having doctor's order on file for R2's half bed rails which poses a potential safety and/or personal rights risks to person in care.
POC Due Date: 09/03/2026
Plan of Correction
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2
3
4
Licensee stated he'll obtain doctor's order and submit copy by 9/03/26.
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 Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2026


LIC809 (FAS) - (06/04)
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