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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200027
Report Date: 11/15/2024
Date Signed: 11/15/2024 07:39:31 PM

Document Has Been Signed on 11/15/2024 07:39 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:
11/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Teresita Aquino and
Noel Fernandez, Staff		TIME VISIT/
INSPECTION COMPLETED:
07:40 PM
NARRATIVE
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At 3:20 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual inspection that was started on November 8, 2024, and met with staff, Teresita Aguino, and informed the reason for visit. LPA called and spoke over the phone with Beth Nunez (administrator (ADM). ADM stated she can not come to the facility, and gave permission to have either Teresita Aquino or Noel Fernandez to sign and receive this report. Noel Fernandez arrived before 5:00 pm.

LPA review 4 residents and 5 staff files. LPA checked the medications and compared with doctor's orders of medication and LIC622 Centrally Stored Medication and Destruction Records. Residents' P&I were checked and compared with last recorded balance.

LPA observed the following:
-at 4:35 pm, resident (R4) has no medical assessment/LIC602 Physician's Report and TB test result on file. Staff Noel Fernandez double checked R4 file and didn't see the TB test record.
-at 4:50 pm, facility does have R1's Fish Oil. R1's March 2024 LIC622 indicated discontinued but LIC602 dated 7/12/24 has Fish Oil listed. It's not clear if this medication is discontinued as there's no discontinued order on file.
-at 5:20 pm, resident (R2) has order for medications but facility does not have 4 of the medications on the list.


......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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Document Has Been Signed on 11/15/2024 07:39 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/15/2024 at 06:55 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: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(A)
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: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in R1 has Fish Oil listed on LIC602 but facility does not have this and no discontinued order on file which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 11/16/2024
Plan of Correction
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Administrator to obtain discontinued order if the medication is no longer needed; otherwise, obtain the medication. Proof to be submitted by 11/16/24.

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: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2024 07:39 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/15/2024 at 06:55 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: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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4
Based on record review, the licensee did not comply with the section cited above in not having 4 of R2's medication listed on order of medications which poses an immediate health and/or personal rights risks to persons in care.
This is a repeat violation within 12 months period, A citation was issued on 11/29/23.
A $250.00 civil penalty is assessed.
POC Due Date: 11/16/2024
Plan of Correction
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Administrator to obtain discontinued order if the 4 medications are no longer needed; otherwise, obtain the medicattions. Proof to be submitted by 11/16/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2024 07:39 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/15/2024 at 06:55 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: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in not obtaining LIC602 for R4 prior to admisssion which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Administrator to set-up an appointment for R2's medical assessment and submit copy of LIC602 by 11/29/24.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

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 in R2 not having TB test which poses a potential health risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Administrator to have R2 TB tested and submit copy of result by 11/29/24.
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: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


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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: 11/15/2024
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation within 12 month of section # 80075(b)(5)(B). Failure to submit proof of corrections by plan of correction due dates may result additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with ADM over the phone and with Noel Fernandez.

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

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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