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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200139
Report Date: 10/19/2023
Date Signed: 10/19/2023 06:49:47 PM

Document Has Been Signed on 10/19/2023 06:49 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: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:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Juliana Taburaza/Licensee and
Shielha Muniiz/Administrator		TIME COMPLETED:
06:50 PM
NARRATIVE
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On this day, October 19, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection and met with staff, Aileen Fajardo and Clara Fajardo. LPA called and spoke with Juliana Taburaza, licensee, and Sheilha Muniz, administrator, and informed the reason for visit. Licensee authorized Aileen Fajardo to be with LPA in touring the facility. Licensee and administrator arrived at around 12:00 noon.

Facility has Infection Control Plan and LPA obtained copy on this day.

LPA toured the facility inside out. LPA inspected the kitchen, dining and activity areas, bathrooms, residents' rooms, laundry room and staff room. Food were checked and observed supplies of 2 days of perishables and 7 days of non-perishables.

Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the bathrooms was tested. Facility conducts disaster drills monthly, and records showed last conducted September 9, 2023.

LPA reviewed 5 staff and 5 residents files, and interviewed 3 residents and 3 staff. Medications checked, and compared with records and doctor's orders. Residents cash resources records reviewed.

LPA observed the following:
-at 11:40 am, hot water temperature at 122degrees Fahrenheit.
-at 2:30 pm, R1's LIC602A indicated R1 needs assistance with all activities of daily living.
-at 3;40 pm, R5's records showed R5 is over 60 years of age

.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139
VISIT DATE: 10/19/2023
NARRATIVE
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LPA received copies of the following current/updated documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)

Administrator to submit copy of proof of Surety Bond coverage by November 2, 2023:

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 violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with licensee and 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: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/19/2023 06:49 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/19/2023 at 05:18 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: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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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Based on observation, the licensee did not comply with the section cited above for hot water temperature at 122 degrees Fahrenheit which poses potential health and/or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Staff adjusted the water temperature while LPA was at the facility.
In addition, administrator to in-service the staff and ensure temperature is kept within Regulations range and submit proof by 11/02/23.
Type B
Section Cited
CCR
80022(e)
Plan of Operation
(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to:

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 in 1 out of 5 residents rely on staff with ADLs and but such is not included in facility's plan of operation which poses a potential health, safety and/or personal rights risk to person in care.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee to submit an Addendum to Plan of Operation by 11/02/2023.
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: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/19/2023 06:49 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/19/2023 at 06:08 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: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
85068.4 Acceptance and Retention Limitations
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.
-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 for R5 who is over 60 years of age making the facility exceeds 25% of the census over age of 60. This poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 10/19/2023
Plan of Correction
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Administrator to submit age exception request along with supporting documents by 11/02/23.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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