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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200027
Report Date: 11/08/2024
Date Signed: 11/08/2024 05:59:35 PM

Document Has Been Signed on 11/08/2024 05:59 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/
DIRECTOR:		BETH NUNEZFACILITY TYPE:
735
ADDRESS:1616 TROWVILLE LANETELEPHONE:
(510) 670-9039
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 4CENSUS: 4DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Teresita Aquino/StaffTIME VISIT/
INSPECTION COMPLETED:
06:10 PM
NARRATIVE
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At 3:45 pm on this day, November 8, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection and met with staff, Teresita Aguino, and informed the reason for visit. LPA called and left message on Beth Nunez's ( administrator (ADM)) voicemail At 4:15 pm, Jordan Nunez, staff, called LPA, but he can not come to the facility.

Facility has Infection Control Plan that was submitted by ADM and received by LPA on December 10, 2023.

LPA toured the facility inside out with Teresita Aquino. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms, 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 ensuite bathroom was tested. Facility conducts disaster drills monthly, and records showed last conducted October 5, 2024.

LPA observed the following:
-at 3:54 pm, resident's medication in the refrigerator.
-at 3.59 pm, knives in the same cabinet where cleaning supplies and toxic agents are kept.
-at 4:01 pm, Ant and Roach Killer in one of the residents rooms.
-at 4:03 pm, ants, mildew and mold in the shower in ensuite bathroom.
-at 4:06 pm, hot water temperature at 99.9 degrees Fahrenheit.
-at 4:09 pm, mold and mildew in the shower in the common bathroom.
-at 4:13 pm, overgrown weeds about 1 to 1 1/2 feet height in the backyard.

.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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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: 11/08/2024
NARRATIVE
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ADM to submit updated copies of the following by November 22, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $250.00 civil penalties are assessed for each of repeat violations within 12 months for deficiency section #'s 80087(a) and 80088(e)(1). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with Jordan Nunez over the phone in the presence of Teresita Aquino. Aquino has to leave at 5:00 pm and relieved by other staff, Noel Fernandez, who signed and receive this report.

Due to time constraint, LPA will come back to continue inspection.

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: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/08/2024 05:59 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/08/2024 at 05:12 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: 11/08/2024

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
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Based on observation, the licensee did not comply with the section cited above in Ant and Roach Killer in the residents' room which poses an immediate health and safety risks to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Staff locked the item.
Administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/09/24.
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
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Based on observation, the licensee did not comply with the section cited above in resident’s medication unlocked in the refrigerator which poses an immediate health and/or safety risks to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Staff locked the medications.
Administrator to do the following and submit proof by 11/09/24:
1. Purchase a medication lock box.
2. In-service the staff.
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: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/08/2024 05:59 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/08/2024 at 05:12 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: 11/08/2024

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
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Based on observation, the licensee did not comply with the section cited above in [the following which pose a potential health and/or personal rights risk to persons in care: mildew and mold in the shower in ensuite bathroom; mold and mildew in the shower in the common bathroom; overgrown weeds about 1 to 1 1/2 feet height in the backyard.
This is a repeat violation within 12 month period. A citation was issued on 11/29/23. A $250.00 civil penalty assessed.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator do to the following and submit pictures by 11/22/24:
1. Have the bathrooms cleaned.
2. Have the yard cleaned.
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

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 ants in the shower in the ensuite bathroom which poses a potential personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator to have the ants exterminated and submit proof by 11/22/24.
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: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/08/2024 05:59 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/08/2024 at 05:12 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: 11/08/2024

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 in hot water at at 99.9 degrees Fahrenheit which poses a potential health and/or personal rights risks to persons in care.
This is a repeat violation within 12 month period. A citation was issued on 11/29/23. A $250.00 civil penalty assessed.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator to have the temperature adjusted within Regulations range and submit proof by 11/22/24.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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