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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200055
Report Date: 12/23/2022
Date Signed: 12/23/2022 03:00:44 PM

Document Has Been Signed on 12/23/2022 03:00 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:HAYWARD HOLY INFANT RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200055
ADMINISTRATOR:SIMPORIANA P. JUGARAPFACILITY TYPE:
735
ADDRESS:2593 BING COURTTELEPHONE:
(510) 471-7303
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
12/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Julieann Carrillo, care staffTIME COMPLETED:
03:10 PM
NARRATIVE
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On 12/23/2022, at 1:05 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by Julieann Carrillo, care staff and explained the purpose of the visit. Administrator SIMPORIANA P. JUGARAP, gave consent to care staff to tour and sign the report on her behalf.

During the inspection, LPA toured facility including but not limited to front entrance, common areas, hand washing stations, bedrooms, bathrooms and back yard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. All sharps and toxins were locked up and inaccessible to clients in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 113.3 Degrees F. Fire extinguisher was last serviced on 7/11/2022. Facilities room temperature is maintained at 71 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are functional. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care.

During record review, LPA observed facility has a copy of their Infection Control Plan and Disaster Plan on file.



Continue on Lic809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2022
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: HAYWARD HOLY INFANT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200055
VISIT DATE: 12/23/2022
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Continued from Lic809

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

At 1:41 PM, LPA observed S1 is not associated through Guardian to be in the facility. Care staff has been working in the facility since February 2022


The amount of $500.00 is being assessed during todays visit.


Exit interview conducted with care staff, appeal rights given along with a copy of this report.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2022 03:00 PM - It Cannot Be Edited


Created By: Liridon Fici On 12/23/2022 at 02:38 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: HAYWARD HOLY INFANT RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(a)
80019 Criminal Record Clearance: (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code Section 1522(b) and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.


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 by not associating S1 in Guardian to be able to work in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2022
Plan of Correction
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Licensee agreed to associate S1 to be able to work in the facility and to email CCL proof of association by POC due date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2022


LIC809 (FAS) - (06/04)
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