019200146-12-23-2025-15-AS-ADEO-DPN3CZ-20251223170847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200146
Report Date: 12/23/2025
Date Signed: 12/23/2025 05:09:01 PM

Document Has Been Signed on 12/23/2025 05:09 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:	PAPAYA CARE HOME		FACILITY NUMBER:	019200146
ADMINISTRATOR/ DIRECTOR:	GALANG, ROSARIO		FACILITY TYPE:	735
ADDRESS:	24782 PAPAYA STREET		TELEPHONE:	(510) 783-5507
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY: 6		CENSUS: 6	DATE:	12/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Maria Theresa "Tek" Ordiniza/Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day, 12/23/25, at 2:00 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Erlie Manansala, and informed the purpose of visit. LPA also met with other staff, Arlan Punongbayan. LPA called and spoke over the phone with Maria Theresa "Tek" Ordiniza, assistant administrator (AADM), who gave permission to Erlie Manansala to be with LPA in touring the facility. AADM arrived at 2:17 pm. LPA started the inspection with Erlie Manansala and continued with AADM. LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining area, living room, garage, side yard and backyard. There is a supply of 7 days of non-perishable and 2 days of perishable foods. Central storage for medications was observed locked. Fire extinguisher was observed fully charge with tag showed serviced 7/19/25. Facility has carbon monoxide and smoke detectors that were tested and observed in operating condition during today's visit. Hot water temperature in the one of common bathrooms was tested and measured at 120 degrees Fahrenheit. Facility conducts fire and earthquake drills every quarter and records showed last conducted 11/02/25. First aid kit checked and observed complete with manual. LPA reviewed 5 residents and 5 staff files. Medications were inspected and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. P&I/cash resources checked and compared with last recorded balance. ..........continued on 809C

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 5

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: 12/23/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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 2:06 pm, peeler in unlocked kitchen drawer.
-at 2:07 pm, knives/sharps stored in kitchen cabinet with cleaning supplies.
-at 2:15 pm, Lysol and Febreeze spray in unlocked staff room.
-at 4:14 pm, quantity of 2 of resident's (R1) medications on the labels do not match the actual quantities received by the facility.

Updated/current copies of the following documents to be submitted by January 6, 2026:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiencies and plan and proof of corrections were discussed with assistant administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 12/23/2025 05:09 PM - It Cannot Be Edited

Created By: Alicia Delmundo On 12/23/2025 at 04:35 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: 12/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in peeler in unlocked kitchen drawer and Lysol and Febreeze spray in unlocked staff room which posed an immediate health, safety or personal rights risks to persons in care.
	POC Due Date: 12/24/2025
	Plan of Correction
1 2 3 4	Staff locked the peeler and staff room. In addition, assistant administrator stated she'll in-service the staff. Proof to be submitted by 12/24/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

	Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 12/23/2025 05:09 PM - It Cannot Be Edited

Created By: Alicia Delmundo On 12/23/2025 at 04:35 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: 12/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80076(a)(15)

Food Service

(a) In facilities providing meals to clients, the following shall apply: (15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in knives/sharps stored in kitchen cabinet with cleaning supplies which poses a potential health and/or personal rights risks to persons in care.
	POC Due Date: 01/06/2026
	Plan of Correction
1 2 3 4	Staff removed the cleaning supplies and locked in the garage. In addition, assistant administrator to in-service the staff and submit copy of training topic with attendees signatures by 1/06/26.

Type B

Section Cited

CCR

80075(k)(3)

80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in quantities of 2 of resident's (R1) medications on the labels do not match the actual quantities received by the facility which posed a potential health and/0r personal rights risks to person in care.
	POC Due Date: 01/06/2026
	Plan of Correction
1 2 3 4	Corrected. Staff obtained the correct labels while LPA was at the facility.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:

	Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5