<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200025
Report Date: 11/09/2024
Date Signed: 11/09/2024 08:09:41 PM

Document Has Been Signed on 11/09/2024 08:09 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/
DIRECTOR:		ADRIAN CARLO ESCUETAFACILITY TYPE:
735
ADDRESS:1873 WEST STREETTELEPHONE:
(510) 397-0354
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 5DATE:
11/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Ramnick 'Ram' Orola/StaffTIME VISIT/
INSPECTION COMPLETED:
08:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, November 9, 2024, at 3:00 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Ramnick 'Ram' Orola, staff, and informed the reason for visit. LPA also met with other staff, Ernesto Cochico. LPA called and left message on Adrian Escueta's (house manager; HM), voicemail. At 4:03 pm, HM returned LPA's call.

Facility has LIC9282 Infection Control Plan that was submitted and received by LPA on 11/30/2023.

LPA inspected the facility inside out with Ramnick Orola. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyard. 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 and measured at 106 degrees Fahrenheit. Facility conducts disaster drills and records showed last conducted 09/2024. Fire extinguisher was observed fully charge with tag showed serviced 03/19/2024.

LPA reviewed 5 staff and 5 residents files, and interviewed 1 resident. 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 23, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage
....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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: 11/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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 violations within 12 month period of section #'s 80087(g) and 80087(a). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

-at 3:17 pm, unlocked residents' medications in the refrigerator in the garage.
-at 3:20 pm, unlocked cleaning, automotive and laundry supplies in the garage.
-at 3:27 pm, heavy stained carpet flooring in resident's room.
-at 3:35 pm broken window and hole in the wall in the other resident's room.
-at 3:36 pm, dusty floor vents,
-at 3:38 pm, dilapidated vanity cabinets, broken paper towel dispenser, dilapidated medicine cabinet, and mildew and mold in bathroom showers.
-from 5:30 pm to 6:00 pm, Physician's Reports of 3 residents (R1, R3 and R4) are over a year old. These residents are over 60 years of age. R1, R2 and R3's LIC625 Appraisal/Needs and Services Plan are over a year old.
-from 6:15 pm to 6:45 pm, all 5 residents' P&I for 11/2024 and expenditures starting 2nd week of 10/2024 not recorded on LIC405 Record Of Client's/Resident's Safeguarded Cash Resources.

Deficiencies, plan and proof of corrections and civil penalties were discussed over the phone with HM over the phone in the presence of the staff. HM gave permission to have Ramnick Orola to sign and receive this report.

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

DATE: 11/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/09/2024 08:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/09/2024 at 06:54 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: 11/09/2024

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 observation, the licensee did not comply with the section cited above in unlocked cleaning, automotive and laundry supplies in the garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2024
Plan of Correction
1
2
3
4
Staff locked the items.
In addition, administrator to in-service the staff and submit copy of trainining topic with attendees signatures by 11/10/24.
Type A
Section Cited
CCR
80075(k)(1)
80075 Health Related Services
(k)…..(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in unlocked residents' medications in the refrigerator which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 11/10/2024
Plan of Correction
1
2
3
4
Staff locked the medications.
In addition, administrator to in-service the staff and submit copy of trainining topic with attendees signatures by 11/10/24.
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: 11/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/09/2024 08:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/09/2024 at 06:54 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: 11/09/2024

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: heavy stained carpet flooring in resident's room; broken window and hole in the wall in the other resident's room; dusty floor vents.
This is a repeat violation within 12 month period. A citation was issued on 11/16/23. A $250.00 civil penalty assessed.
POC Due Date: 11/23/2024
Plan of Correction
1
2
3
4
Administrator to do the following and submit pictures by 11/23/24:
1. Have the carpet and vents cleaned.
2. Have the window repaired/fixed.
3. Patch the hole.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: dilapidated vanity cabinets, broken paper towel dispenser, dilapidated medicine cabinet, and mildew and mold in the shower in the bathrooms.
POC Due Date: 11/23/2024
Plan of Correction
1
2
3
4
Administrator to do the following and submit pictures by 11/23/24:
(1) Have the cabinets replaced or repainted; (2) Replace the towel dispenser; (3) Replace the medicine cabinet; (4) Have the bathrooms cleaned.
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: 11/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/09/2024 08:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/09/2024 at 06:54 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: 11/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in R1, R2 and R3's LIC625 Appraisal/Needs and Services Plan over a year old which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 11/23/2024
Plan of Correction
1
2
3
4
Administrator to update the LIC625 and submit self-certification by 11/23/24.
Type B
Section Cited
CCR
85068.4(e)
85068.4 Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in over a year old Physician's Reports of R1, R3 and R4 who are over 60 years of age which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 11/23/2024
Plan of Correction
1
2
3
4
Administrator to set up doctor's appointment for R1, R3 and R4, and submit copies of updated LIC602A by 11/23/24.
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: 11/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/09/2024 08:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/09/2024 at 07:32 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: 11/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care……

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in 5 out of 5 residents' P&I for November 2024 and expenditures from October 2024 not recorded on LIC405 which pose a potential personal rights risks to persons in care.
POC Due Date: 11/23/2024
Plan of Correction
1
2
3
4
Administrator to complete the LIC405 and submit self-certifcation by 11/23/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 11/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2024


LIC809 (FAS) - (06/04)
Page: 6 of 6