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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200139
Report Date: 09/11/2024
Date Signed: 09/11/2024 06:29:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20221202112716
FACILITY NAME:NEW BELLEVUE MANORFACILITY NUMBER:
019200139
ADMINISTRATOR:SHIELHA MUNIZFACILITY TYPE:
735
ADDRESS:3056 RANDALL WAYTELEPHONE:
(510) 538-3053
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:12CENSUS: 8DATE:
09/11/2024
UNANNOUNCEDTIME BEGAN:
06:15 PM
MET WITH:Juliana Taburaza/Licensee and
Sheilha Muniz/Administrator 		TIME COMPLETED:
06:35 PM
ALLEGATION(S):
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Staff not following proper Covid-19 testing protocols.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Juliana Taburaza, licensee, and Sheilha Muniz, administrator, and informed the purpose of visit.

During the course of investigation, LPA obtained copies residents' COVID-19 symptoms screening and temperature records and resident's RCEB Placement Information. LPA reviewed the SIR submitted by licensee to the Department. LPA interviewed staff (S1, S2) on 12/09/22.


......continued on 9099C (page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20221202112716
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139
VISIT DATE: 09/11/2024
NARRATIVE
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Page 2

Reporting party stated that the family member (FM1) reported that when FM1 took R1 home from the facility on 11/29/22, 3 tests done during R1’s stay at the family and results were all positive. When FM1 droved R1 back to the facility on 12/01/22, staff was informed that R1 tested positive. Staff stated she would test R1 again. FM1 stayed and observed when test was conducted, and staff did not perform the test accurately, not swabbing the nostril correctly or waiting for the required time for the result. FM1 stated that after few minutes, staff showed the result as negative. FM1 told the staff she has to wait 15 minutes for the result.

Although both S1 and S2 demonstrated to LPA the proper use of the test kit, one of these staff stated not waiting for 15 minutes for the result when she tested R1; she only waited for 5 minutes when she tested R1 in the presence of the family member because R1 was not exhibiting symptoms.

Based on information obtained, the preponderance of evidenced is met, therefore the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12-month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed.

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: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20221202112716
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2024
Section Cited
CCR
85095.5(a)
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85095.5 Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained.

-This requirement is not met as evidenced by:
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Administrator to in-service the staff and submit proof by 9/12/24.
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-Based on interview and records review, the licensee did not comply with the section above for not following the proper procedure in conducting Covid-19 antigen testing which posed an immediate risk to persons in care.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20221202112716

FACILITY NAME:NEW BELLEVUE MANORFACILITY NUMBER:
019200139
ADMINISTRATOR:SHIELHA MUNIZFACILITY TYPE:
735
ADDRESS:3056 RANDALL WAYTELEPHONE:
(510) 538-3053
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:12CENSUS: 8DATE:
09/11/2024
UNANNOUNCEDTIME BEGAN:
06:15 PM
MET WITH:Juliana Taburaza/Licensee and
Sheilha Muniz/Administrator 		TIME COMPLETED:
06:35 PM
ALLEGATION(S):
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Allegation: Staff are not ensuring that facility's heating system is in working condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Juliana Taburaza, licensee, and Sheilha Muniz, administrator, and informed the purpose of visit.

During the course of investigation, LPA reviewed the Special Incident Report (SIR) submitted by the facility to the Department. On 12/09/22, LPA conducted inspection, interviewed staff (S1 and S2) and residents (R1 and R2), and obtained copy of proof of repair of heater.

During inspection, LPA observed the centralized heater working and temperature inside the facility at 69 degrees Fahrenheit. LPA also observed portable heaters in the living room and residents’ rooms.

....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20221202112716
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139
VISIT DATE: 09/11/2024
NARRATIVE
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Page 2

Both S1 and S2 confirmed the heater stopped working on 12/01/22 and licensee called for service and heater was repaired. Proof of service confirmed staff’s statements. Staff also stated the facility already has 2 portable heaters, but licensee brought more portable heaters on 12/01/22.

R1 stated it was never cold in her room while R2 stated she never had problem with the temperature in her room and that there’s portable heater in her room since she moved-in years 6 years prior to the said incident.

Based on information gathered, the allegation is closed as substantiated. An unsubstantiated findings means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5