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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200020
Report Date: 07/03/2024
Date Signed: 07/03/2024 01:34:32 PM

Document Has Been Signed on 07/03/2024 01:34 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:GOOD SAMARITAN RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200020
ADMINISTRATOR/
DIRECTOR:		FRANKLIN E. BAUTISTAFACILITY TYPE:
735
ADDRESS:275 JACKSON STREETTELEPHONE:
(510) 886-1821
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
07/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Frankline Bautista, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 7/3/2024, Licensing Program Analyst (LPA) Kelly Nguyen conducted an unannounced case management regarding an incident report that was submitted to CCLD on 5/21/24 regrading a Client had a pressure 4 injury. LPA explained to Administrator (AD), Frank the purpose of the visit.

LPA obtained and reviewed physician's report for Client 1 (C1). LPA interview AD regarding the incident. AD stated when C1 was discharge they never mentioned anything about C1 having stage 4 injury.AD read the after-visit summary and noticed that the hospital had stated C1 condition with a stage 4 injury, but they never verbally mention to me. I call the hospital back right away, but they indicated that C1 is already discharge. Prior to C1 came back from the facility C1 was staying in Mc Clure (post-acute care rehab facility). I noticed that C1 had an injury on C1 right thumb. I tried contacting them to injured about C1 thumb, but no one answer. I called 911 because C1 was having difficult breathing, and at the same time I asked them to check C1 right thumb. I even contact Mc Clure rehab. To asked them what happened, but I still didn’t get an answer. After that I contact home health and ask them to come and assisted C1 after I know that C1 was having stage 4. Therefore, facility is admitting client with stage 4 pressure injury.


Per Title 22 Regulations, the deficiency will be cited on the LIC 809D.

LPA went over the report with Frank and provided a copy with the appeal rights via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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Document Has Been Signed on 07/03/2024 01:34 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 07/03/2024 at 01:24 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: GOOD SAMARITAN RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2024
Section Cited
CCR
80091(a)(4)

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80091 Prohibited Health Conditions
(a) In adult CCFs clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained.
(4) Stage 3 and 4 dermal ulcers.

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Administrator will review the regulation and submit a self-certify letter indicating that he had review the regulation to CCLD by POC date.
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This requirement is not met as evidence by:

Facility is admitting client with stage 4 pressure injury.
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024


LIC809 (FAS) - (06/04)
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