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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200139
Report Date: 09/11/2024
Date Signed: 09/11/2024 06:09:46 PM

Document Has Been Signed on 09/11/2024 06:09 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/
DIRECTOR:		SHIELHA MUNIZFACILITY TYPE:
735
ADDRESS:3056 RANDALL WAYTELEPHONE:
(510) 538-3053
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 12CENSUS: 8DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Juliana Taburaza/Licensee and
Sheilha Muniz/Administrator 		TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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At 11:40 am on this day, September 11, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Estelita Tubangui. LPA met with Juliana Taburaza, licensee, and Sheilha Muniz, administrator, and informed the reason for visit.

Facility has Infection Control Plan and a copy was obtained by LPA on October 19, 2023.

LPA toured the facility inside out with the administrator. LPA inspected the kitchen, dining and activity areas, bathrooms, residents' rooms, laundry room, side yard and backyard. Food were checked and observed supplies of 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has 2 in 1 smoke and carbon monoxide detector that was tested and observed functional. Hot water temperature in one of the bathrooms was tested. Facility conducts fire and earthquake drills monthly, and records showed last conducted September 1, 2024 and September 2, 2024 respectively.

LPA reviewed 5 staff and 5 residents files, and interviewed 1 resident and 1 staff. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Residents cash resource record reviewed and compared with last recorded balance.

LPA observed the following:
-at 12:08 pm, hot water temperature at 129 degrees Fahrenheit.
-from 12:18 pm to 12:20 pm, pieces of wood, cabinets, used mattress and bed in the backyard.

.....continued on 809C (page 2)
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.

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: 09/11/2024
NARRATIVE
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Page 2

-at 2:40 pm, resident (R2) LIC602A Physician's Report indicated R2 has dementia but facility does not have dementia care program/plan nor submitted an exception request to retain R2.
-at 3:45 pm, residents' (R1, R4 and R5) P&I not available for review.

Licensee or administrator to submit copies of the following current/updated documents by September 25, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section # 80088(e)(1) within 12 month period. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies, plan and proof of corrections, and civil penalty were discussed with licensee and administrator

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, 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
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/11/2024 06:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/11/2024 at 04:44 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: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024

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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Based on observation, the licensee did not comply with the section cited above in hot water temperature at 129 degrees Fahrenheit which poses an immediate safety and/or personal rights risks to persons in care.
This is a repeat violation within 12 month period. The first citation was issued on 10/19/23.
POC Due Date: 09/12/2024
Plan of Correction
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Corrected.
Staff adjusted the temperature to 107 degrees Fahrenheit.
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: 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


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/11/2024 06:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/11/2024 at 04:44 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: NEW BELLEVUE MANOR
FACILITY NUMBER: 019200139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 in the following which pose a potential safety and/or personal rights risks to persons in care: pieces of wood, cabinets, used mattress and bed in the backyard.
POC Due Date: 09/25/2024
Plan of Correction
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Licensee or administrator to have the items disposed and cleaned the backyard. Pictures to be submitted by 9/25/24.
Type B
Section Cited
CCR
80070(d)
80070 Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above for not having residents' (R1, R4 and R5) P&I available for review which poses a potential personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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In the future, licensee to ensure records and P&I are made available for review. Self-certification to be submitted by 9/25/24.
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: 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2024 06:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/11/2024 at 05:07 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: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(b)(2)
80022 Plan of Operation
(b) The plan and related materials shall contain the following:
(2) Statement of admission policies and procedures regarding acceptance of clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in retaining R2 who has dementia when facility does not have dementia care program/plan nor have submitted an exception request which poses a potential health, safety and/or personal rights risk to person in care.
POC Due Date: 09/25/2024
Plan of Correction
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Licensee stated she'll submit an exception request by 9/25/24. Request to indicate how facility will keep R2 safe and meet the care needs. Request to be submitted along with including but not limited to the following: LIC602A Physician's Report; LIC9172 Functional Capability Assessment; LIC625 Appraisal/Needs and Services Plan; staff training; letter of support from R2's responsible person
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: 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


LIC809 (FAS) - (06/04)
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