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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200055
Report Date: 01/24/2024
Date Signed: 01/24/2024 05:00:58 PM

Document Has Been Signed on 01/24/2024 05:00 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:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Simporiana JugarapTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility at around 2pm to conduct an annual required inspection and met with staff Julie Carrillo. LPA explained to Carrillo the purpose of the visit. The Administrator arrived at around .

During the visit, LPA inspected the facility inside and out including but not limited to client rooms, bathrooms, kitchen, dining area and backyard. Hot water measured at 106.7 Fahrenheit. There was sufficient supply of perishable and non perishable foods. Smoke detectors and carbon monoxide were tested and observed operational. Fire extinguisher appeared full and was last serviced on 2/22/2023. Medications were observed locked in a cabinet in the hallway.

LPA observed the following: right side gate does not open easily, mold on window frames, part of backyard fence leaning towards the neighbor's side.

At 2:30 pm, LPA reviewed 5 client files and 3 staff files. All staff are fingerprint cleared and associated to the facility.At 4:20 pm, LPA reviewed P&I money and log. Facility has sufficient surety bond to cover amount of cash being handled at one time.

The following records were requested to be submitted to CCL by cob Friday, 1/26/24: Lic 500, Client Roster, Emergency Disaster Plan, Surety Bond, Liability Insurance, Fire Drill, Vehicle Registration and Insurance and Driver's License.

Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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 01/24/2024 05:00 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 01/24/2024 at 04:46 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: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)


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 (please see below) which poses/posed a potential health, safety or personal rights risk to persons in care.
1. right side gate does not open easily 3. mold on window frames
2. backyard fence leaning towards neighbor
POC Due Date: 02/07/2024
Plan of Correction
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Administrator will get right side gate and fenced fixed and window frames get cleaned. Administrator will submit photo proof of fixed fence and windows cleaned. For the gate, Administrator will provide self-certification of completion of new gate.
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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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