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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200130
Report Date: 01/12/2024
Date Signed: 01/12/2024 06:00:49 PM

Document Has Been Signed on 01/12/2024 06:00 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:BISHOP ADULT RES. CAREFACILITY NUMBER:
019200130
ADMINISTRATOR:LILIBETH ORDINIZAFACILITY TYPE:
735
ADDRESS:758 BISHOP AVETELEPHONE:
(510) 586-0266
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Onesty Hill/Staff and
Lilibeth Ordiniza/Administrator		TIME COMPLETED:
06:05 PM
NARRATIVE
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On this day, January 12, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Onesty Hill, and informed the reason for visit. LPA called and spoke over the phone with Lilibeth 'Beth' Ordiniza, administrator. Administrator arrived at around 1:15 p.m. with other staff, Martin Concepcion. LPA also met with other staff, Rachel Neak.

Administrator submitted the facility's Infection Control Plan which LPA received on January 11, 2024.

LPA toured the facility inside out with Onesty Hill. LPA inspected the kitchen, dining areas, living and family rooms. bedrooms, bathroom. side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and storage for cleaning supplies were observed locked.

Facility has carbon monoxide and smoke detectors that were tested, and observed functional. Facility conducts earthquake and fire drills at least every quarter, and records showed last conducted December 2023 and November 2023 respectively. Fire extinguisher checked, observed fully charge with tag showed serviced May 31, 2023. Hot water temperature was tested.

LPA reviewed 5 staff and 5 residents records, and interviewed 2 staff and 2 residents. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. P&I were checked against records.


....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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: BISHOP ADULT RES. CARE
FACILITY NUMBER: 019200130
VISIT DATE: 01/12/2024
NARRATIVE
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LPA received the following updated/current documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage
5. Current Lease Agreement

LPA observed the following:
-at 12:36 p.m., rubbing alcohol and Pepto Bismol in resident's room.
-at 12:45 p.m., hot water temperature at 132.5 degrees Fahrenheit.
-at 4:00 p.m., there's no doctor's order on file for resident's (R1) medications
-at 4:20 p.m., resident (R2) has order for diphenhydramine HCl (50 mg) capsule but facility does not have this medication.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

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

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/12/2024 06:00 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/12/2024 at 05:32 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: BISHOP ADULT RES. CARE
FACILITY NUMBER: 019200130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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2
3
4
Based on observation, the licensee did not comply with the section cited above for hot water temperature at 132.5 degrees Fahrenheit which poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 01/13/2024
Plan of Correction
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3
4
Corrected.
Staff adjusted the temperature to 116 degrees Fahrenheit while LPA was at the facility.
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above for R2 who has doctor's order for 1 medication does not have it which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 01/13/2024
Plan of Correction
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Administrator to check with the doctor if the medication is no longer needed and obtain discontinued order; otherwise, obtain the medication . Proof to be submitted by 1/13/24.
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: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/12/2024 06:00 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/12/2024 at 05:32 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: BISHOP ADULT RES. CARE
FACILITY NUMBER: 019200130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above for not having doctor's order on file for R1's medications which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 01/13/2024
Plan of Correction
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Administrator to obtain doctor's order and submit copy by 1/13/24.

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: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


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Page: 4 of 5
Document Has Been Signed on 01/12/2024 06:00 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/12/2024 at 05:44 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: BISHOP ADULT RES. CARE
FACILITY NUMBER: 019200130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings 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 sbove for rubbing alcohol and Pepto Bismol in the resident's room which poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 01/13/2024
Plan of Correction
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Staff locked the items.
In addition, administrator to do in-service and submit copy of training topic with attendees signtures by 1/13/24.
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: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
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