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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200146
Report Date: 12/14/2023
Date Signed: 12/14/2023 05:04:35 PM

Document Has Been Signed on 12/14/2023 05:04 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: 6DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Maria Theresa "Tek" Ordiniza/Assistant Administrator TIME COMPLETED:
05:10 PM
NARRATIVE
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On this day, December 14, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by Arlan Punongbayan, staff. LPA also met with other staff, Erlie Manansala. LPA called and spoke with Assistant Administrator Maria Theresa "Tek" Ordiniza who authorized to start the inspection with Erlie Manansala. LPA also spoke over the phone with Rosario Galang, administrator. Assistant administrator arrived after several minutes.

Facility's Infection Control Plan was submitted and received by LPA on June 30, 2022.

LPA started the inspection with Erlie Manansala and continued with the assistant administrator. LPA inspected the kitchen, dining area, living room, bedrooms, common areas, bathrooms, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has smoke and carbon monoxide detectors that were tested, and observed functional. Facility conducts disaster drills every quarter, and records showed last conducted December 6, 2023. Fire extinguisher checked, observed fully charge with tag showed serviced June 22, 2023. Hot water temperature in the one of the common bathrooms was tested.

LPA reviewed 5 staff and 5 residents files, and interviewed 2 staff and 2 residents. Medications inspected and compared with records and doctor's orders. Residents P&I checked and compared with records.


.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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: PAPAYA CARE HOME
FACILITY NUMBER: 019200146
VISIT DATE: 12/14/2023
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,

The following deficiencies were observed and 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.

-at 12:12 pm, hot water temperature at 133.3 degrees Fahrenheit.
-at 1:35 pm, Surety Bond coverage not sufficient for the total amount of P&I facility handles at a time.
-at 3:30 pm. doctor's order on file for 1 of resident's (R3) medications is 1000 mg but on facility's hand is 125 mg.
-at 4:00 pm, doctor's order for 1 of R5's medications is 40 mg, but the medication on facility's hand is 60 mg.

Deficiencies and plan and proof of corrections were discussed with the assistant 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: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/14/2023 05:04 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/14/2023 at 04:25 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: 12/14/2023

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 for hot water at 133.3 degrees Fahrenheit which poses an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Staff adjusted the water temperature to 116.4 degrees Fahrenheit.
In addition. assistant administrator stated she'll have the staff check the temperature weekly. Self-certification to be submitted by 12/15/23.
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 in 2 (R3 and R5) out of 5 residents' actual medications (1 medication for each) do not match the doctor's orders on file which pose an immediate health and/or personal rights risk to persons in care.
POC Due Date: 12/16/2023
Plan of Correction
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Administrator to check with the physician and obtain correct doctor's order and submit copies by 12/15/23.
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: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/14/2023 05:04 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/14/2023 at 04:40 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: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(c)
80025 Bonding (c) The amount of the bond shall be according to the following schedule:
AMOUNT SAFEGUARDED PER MONTH BOND REQUIRED .
$750 or less $1,000
$751 to $1,500 $2,000
$1,501 to $2,500 $3,000
Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond
-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 sufficient Surety Bond coverage for the total P&I facility handles at a time which poses a potential personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator to obtain addtional coverage and submit proof along with updated LIC400 by 12/28/23.
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: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


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