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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200025
Report Date: 11/16/2023
Date Signed: 11/16/2023 08:23:19 PM

Document Has Been Signed on 11/16/2023 08:23 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:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Adrian Escueta/Administrator TIME COMPLETED:
08:25 PM
NARRATIVE
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On this day, November 16, 2023, at 12:25 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Adrian Escueta, administrator, and informed the reason for visit. LPA also met with Lina Lingat, staff. There were 3 residents in the facility when LPA arrived.

Facility has LIC808 Mitigation Plan but has not submitted the Infection Control Plan.

LPA toured the facility inside out. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, yard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has smoke and carbon monoxide detectors that were tested, and observed functional. Hot water temperature in one of the bathrooms was tested. Facility conducts disaster drills.

LPA reviewed 5 staff and 5 residents files, and interviewed 2 staff and 2 residents. Medications checked, and compared with records and doctor's orders. Residents P&I checked and compared with records.

The following current/updated documents to be submitted by November 30, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage
5. Infection Control Plan

......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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: 11/16/2023
NARRATIVE
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The following deficiencies were observed, cited from Title 22 California Code of Regulations, and listed on 809Ds. A civil penalty of $250.00 is assessed for repeat violation of section 80088(e)(1) within 12 month period. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

-at 12:50 pm. hot water at 125.5 degrees Fahrenheit
-at 12:54 pm, Ca-Rezz anti-bacterial ointment/cream in one of the residents rooms.
-at 12:56 pm, 2 residents rooms with strong smell of urine
-at 12:59 pm, Lysol spray and alcohol in unlocked garage.
-at 1:03 pm, bleach and rake in the yard
-at 1:04 pm, fluorescent bulbs and wet soiled area rug in the yard.
-at 2:36 pm, record showed disaster drill last conducted 6/16/23.
-at 2:50 pm, Adrian Escueta's administrator certificate expired 10/22/23.
-at 4:25 pm, resident R3 and R4 have no Pre-Admission Appraisal on file.
-at 4:35 pm, resident R4 is over 60 years of age.
-at 6:25 pm, R3's 3 medications not recorded on LIC622 Centrally Stored Medication and Destruction Record. Dates medications started for 5 residents not recorded on LIC622.

Deficiencies and plan and proof of corrections were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/16/2023 08:23 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/16/2023 at 06:35 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: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on oservation, the licensee did not comply with the section cited above for Ca-Rezz anti-bacterial ointment/cream, Lysol spray, alcohol, bleach and rake readily accessble to residents which poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Administrator locked all the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/17/23.
Type A
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 for hot water at 125.5 degrees Fahrenheit which poses an immediate safety risk to persons in care.
This is a repeat violation within 12 month period.
A $250.00 civil penalty is assessed.
POC Due Date: 11/17/2023
Plan of Correction
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Corrected. Administrator adjusted the temperature to 105.8 degrees Fahrenheit.
In addition, admininistrator to have the temperature checked on a weekly bais.
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/16/2023 08:23 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/16/2023 at 06:35 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: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, licensee did not comply with the section cited above for the following: fluorescent bulbs and wet soiled area rug in the yard; (2) strong smell of urine in 2 residents rooms. These pose potential safety and/or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Staff cleaned the yard.
In addition, administrator to have the residents rooms deep cleaned. Self-certification to be submiited by 11/30/23.
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for not conducting disaster drill at least once every 3 months which poses a potential safety risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Administrator to conduct disaster drill and submit copy by 11/30/23,
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/16/2023 08:23 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/16/2023 at 06:35 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: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for expired administrator certificate which poses potential personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Administrator stated he'll have the licensee take over the administrator position while he is the process of renewing his certifiate. A signed letter indicating change of administrator and copy of licensee's current certiicate to be submitted by 11/30/23.
Type B
Section Cited
CCR
85068.2(b)(1)(G)
85068.2 Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include:
(1)(G) The licensee shall document the results of the initial assessment of the client, conducted pursuant to Health and Safety Code section 1180.4(a) prior to or on the day of admission.

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 2 out of 5 residents (R3 and R4) not having Pre-Admission Appraisal which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Administrator to complete the Pre-Admission Appraisal and submit self-certification by 11/30/23.
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/16/2023 08:23 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/16/2023 at 07:35 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: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)

85068.4 Acceptance and Retention Limitations
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on records review, the licensee did not comply with the section cited above for 4 residents over years of age making the facility exceeds the allowable 50% of census over age 60 which poses a potential personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Administrator to submit an age exception request for R4 along with supporting documents by 11/30/23.
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

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 for R3's 3 medications not recorded on LIC622 and dates medications started for all 5 residents not recorded on LIC622s which pose a potential personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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2
3
4
Administrator to complete the LIC622s and submit self-certificaiton by 11/30/23.
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
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