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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200025
Report Date: 11/18/2022
Date Signed: 11/18/2022 05:05:32 PM

Document Has Been Signed on 11/18/2022 05:05 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:ESCUETA CARE HOMEFACILITY NUMBER:
019200025
ADMINISTRATOR:ADRIAN CARLO ESCUETAFACILITY TYPE:
735
ADDRESS:1873 WEST STREETTELEPHONE:
(510) 397-0354
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 6DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:37 PM
MET WITH:Milanette Escueta- AdministratorTIME COMPLETED:
05:15 PM
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On 11/18/2022, at 3:37 PM, Licensing Program Analyst (LPA) Liridon Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by care staff. At 3:55 PM, Milanette Escueta- Administrator (ADM) arrived and met with LPA.

During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All sharps and toxins were locked up and inaccessible to clients in care. Common areas are disinfected frequently throughout the day. Fire extinguisher was last serviced on 3/31/2022. Facilities room temperature is maintained at 73 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are operable. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care.


Continue on Lic809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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: ESCUETA CARE HOME
FACILITY NUMBER: 019200025
VISIT DATE: 11/18/2022
NARRATIVE
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Continued from Lic809

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

1. At 3:45 PM, LPA observed staff member is not associated to this facility.

2. At 4:30 PM, LPA observed water temperature measured at 150.3 in common area bathroom.


Exit interview conducted with Administrator, and appeal right provided along with this report.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/18/2022 05:05 PM - It Cannot Be Edited


Created By: Liridon Fici On 11/18/2022 at 04:38 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: ESCUETA CARE HOME
FACILITY NUMBER: 019200025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 by having water temperature measured at 150.3 in common area bathroom, which poses a potential health and safety risk to persons in care.
POC Due Date: 11/25/2022
Plan of Correction
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Administrator agreed to check and maintain water temperature from 105-120 Degrees F. and to submit proof of corrected water temperature to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2022 05:05 PM - It Cannot Be Edited


Created By: Liridon Fici On 11/18/2022 at 04:44 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: ESCUETA CARE HOME
FACILITY NUMBER: 019200025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance:

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 80019(f).

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 not associating care staff to this facility, which poses a potential health and safety risk to persons in care.
POC Due Date: 11/25/2022
Plan of Correction
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Administrator agreed to associate care staff to this facility and to inform CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
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