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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200027
Report Date: 11/29/2023
Date Signed: 11/29/2023 05:48:29 PM

Document Has Been Signed on 11/29/2023 05:48 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:REMINGTON CARE HOMEFACILITY NUMBER:
019200027
ADMINISTRATOR:BETH NUNEZFACILITY TYPE:
735
ADDRESS:1616 TROWVILLE LANETELEPHONE:
(510) 670-9039
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 4CENSUS: 4DATE:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Noel Fernandez/StaffTIME COMPLETED:
05:50 PM
NARRATIVE
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On this day, November 29, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection and met with staff, Noel Fernandez, and informed the reason for visit. LPA called and left message on Beth Nunez, administrator. At 11:24 am. administrator returned LPA's call and stated she can not come to the facility at the moment. Administrator arrived at 3:30 pm.

Facility has LIC808 Mitigation Plan; however, administrator has not submitted the LIC9282 Infection Control Plan.

LPA toured the facility inside out with Noel Fernandez. LPA inspected the living room, dining, kitchen, bathrooms, residents and staff room, garage. front, side and backyard. Food were checked and observed supplies of 2 days of perishables and 7 days of non-perishables.

Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in the 2 bathrooms were tested. Facility conducts disaster drills monthly, and records showed last conducted November 6, 2023.

LPA reviewed 5 staff and 4 residents files, and interviewed 3 residents and 1 staff. Medications checked, and compared with records and doctor's orders. Residents cash resources records reviewed.

LPA observed the following:
-at 11:07 am, hot water temperature at 98.2 degrees Fahrenheit.
-at 11:10 am, missing drawer in one of the residents rooms.

.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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: REMINGTON CARE HOME
FACILITY NUMBER: 019200027
VISIT DATE: 11/29/2023
NARRATIVE
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-at 11:30 am, trash bin in the kitchen without lid.
-at 12:10 pm, observed R1 uses walker to ambulate. R1's LIC602 Physicians Report dated 1/24/22 & 11/04/20 indicated non-ambulatory. Staff interviewed stated R1 needs walker to move around.
-at 1:25 pm, R1's LIC9172 Functional Capability Assessment dated 1/25/21 incomplete- information on walking, repositioning, wheelchair, vision, bathing, dressing, toileting, grooming, transferring were left blank
-at 1:30 pm, R1's LIC625 Appraisal/Needs and Services Plan on file over 5 yrs old (dated 11/23/15)
-at 3:15 pm, R1's LIC602 dated 1/24/22 indicated Ariproprazole (Abilify) 50 mg but the medication on hand is 30 mg
-at 3:45 pm, LIC22 Centrally Stored Medication and Destruction Records of 4 residents do not have dates listed medications were filled.

Administrator to submit copies of the following current/updated documents by December 13, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. LIC9282 Infection Control Plan
5. Proof of Surety Bond coverage

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 80020(a) and will continue for $100.00 per day until corrected.

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

Exit interview conducted. Appeal Rights, LIC421IM 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: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/29/2023 05:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/29/2023 at 04:15 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: REMINGTON CARE HOME
FACILITY NUMBER: 019200027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above for R1 being non-ambulatory and facility is not fiire-cleared and not licensed for non-ambulatory which poses an immediate safety risk to person in care.
POC Due Date: 12/01/2023
Plan of Correction
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2
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Administrator stated she'll issue an eviction. Copy to be submitted by 12/01/23.
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for R1's 1 medication on facility hand not matching the dosage on the Physician's Report which poses an immediate health and/or personal rights risk to person in care.
POC Due Date: 12/01/2023
Plan of Correction
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Corrected.
Admininistrator obtained doctor's order while LPA was at the facility.
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: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/29/2023 05:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/29/2023 at 04:15 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: REMINGTON CARE HOME
FACILITY NUMBER: 019200027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023

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, the licensee did not comply with the section cited above for missing drawer in one of the residents rooms which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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Administrator stated she'll have the drawer replaced, Picture to be submitted by 12/13/23.
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 for hot water temperature at 98.2 degrees Fahrenheit which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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Admnistrator to have the temperature adjusted within Regulations range and sbumit proof by 12/13/23.
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: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/29/2023 05:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/29/2023 at 04:15 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: REMINGTON CARE HOME
FACILITY NUMBER: 019200027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above for trash bin in the kitchen without lid which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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Administrator to purchase trash bin with lid and submit proof by 12/13/23.
Type B
Section Cited
CCR
85068.2(b)(1)(F)
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) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

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 R1's LIC9172 incomplete which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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Administrator to complete the LIC9172 and submit copy by 12/13/23.
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: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/29/2023 05:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/29/2023 at 04:15 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: REMINGTON CARE HOME
FACILITY NUMBER: 019200027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023

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
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above for R1's LIC625 Appraisal/Needs and Services Plan not updated which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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2
3
4
Administrator to update the LIC625 and submit copy by 12/13/23.
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 record review, the licensee did not comply with the section cited above in 4 out of 4 residents' LIC622 not complete. Dates medications were fiilled not recorded which pose a potential personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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Administrator to complete all LIC622 and submit sefl-certification by 12/13/23.
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: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
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