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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200146
Report Date: 03/23/2022
Date Signed: 03/23/2022 05:57:28 PM

Document Has Been Signed on 03/23/2022 05:57 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:PAPAYA CARE HOMEFACILITY NUMBER:
019200146
ADMINISTRATOR:GALANG, ROSARIOFACILITY TYPE:
735
ADDRESS:24782 PAPAYA STREETTELEPHONE:
(510) 783-5507
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 5DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Maria Theresa "Tek" Ordiniza/Assistant Administrator TIME COMPLETED:
06:00 PM
NARRATIVE
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icensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Assistant Administrator Maria Theresa "Tek" Ordiniza and informed the purpose of visit.

Facility has an approved LIC808 COVID-19 Mitigation Plan and all staff were fit tested for N95 respirators.

LPA inspected the facility inside out with Maria Theresa "Tek" Ordiniza. LPA observed screening station by the front entrance with visitor's log, hand sanitizer, surgical masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and clients and recorded daily. Trash bins were observed with pedal operated lids. Centrally stored PPEs inspected and observed adequate. There were COVID-19 signages/posters all throughout the facility and hand washing signs on all bathroom/toilets. Food supplies were observed adequate of 7 days non-perishables and 2 days of non-perishables. .

Fire extinguisher inspected with tag showed serviced June 22, 2021 and observed fully charged.
Smoke and carbon monoxide detectors tested and observed operational. First aid kit was observed complete with manual.

At 4:25 pm, LPA tested the water temperature in one of the bathrooms and measured at 124.4 degrees Fahrenheit.



.......continued next page (809C)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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: PAPAYA CARE HOME
FACILITY NUMBER: 019200146
VISIT DATE: 03/23/2022
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On this day, LPA obtained copies of the following updated documents:
1. LIC500 Personnel Report
2. LIC610D Emergency Disaster Plan.

Licensee to submit copies of the following by April 6, 2022.
1. LIC308 Designation of Facility Responsibilty
2. Proof of Surety bond coverage

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed with Shirley over the phone in the presence of Stephanie.

Exit interview conducted. Appeal Rights, LIC9098 and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/23/2022 05:57 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/23/2022 at 05:17 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: PAPAYA CARE HOME
FACILITY NUMBER: 019200146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)

80088 Furniture, Fixtures, 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. Hot water temperatire was tested at 124.4 degrees Fahrenheit which poses an immediate health and personal rights risk to persons in care.
POC Due Date: 03/24/2022
Plan of Correction
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Gauge was adjusted and hot water temperature was lowered to 112 degrees Fahrenheit while LPA was still at the facility
In addition, administrator to in-service the staff and ensure the water temperature is within Regulations range. Proof to be submitted by 3/24/2022.
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: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022


LIC809 (FAS) - (06/04)
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