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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200148
Report Date: 02/24/2023
Date Signed: 02/24/2023 01:00:20 PM

Document Has Been Signed on 02/24/2023 01:00 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:REMINGTON CARE HOME #2FACILITY NUMBER:
019200148
ADMINISTRATOR:BETH NUNEZFACILITY TYPE:
735
ADDRESS:27481 ORLANDO AVETELEPHONE:
(510) 785-9215
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 5DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rogelio Cruz, CaregiverTIME COMPLETED:
01:15 PM
NARRATIVE
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On 02/24/2023 at 11:00AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Rogelio Cruz and explained the purpose of the visit. LPA spoke with Administrator, Armenio Nunez he okayed Caregiver to sign documents.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas and kitchen. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

LPAs observed the following deficiencies during today's POC visit:

-LPA observed stain remover and oxy clean located in a cabinet under the bathroom sink
-LPA observed that the side yard gate was locked with a keyed lock.

An immediate civil penalty of $500.00 will be assessed on today's date for a (locked gate) Fire Clearance violation 80020(a).

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148
VISIT DATE: 02/24/2023
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Continue from LIC809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/03/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2023 01:00 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Carol Fowler On 02/24/2023 at 12:26 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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type A
Section Cited
CCR
80020(a)
80020(a)

Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, licensee did not comply with the section cited above by having the locked gate that was not originally approved by the fire department which poses an immediate health and safety risk to the clients in care..
POC Due Date: 02/25/2023
Plan of Correction
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Administrator will removed the lock and provide CCLD with photo copies no later then the POC date.

$500 Civil Penalty was assessed.
Under Appeal
Type A
Section Cited
CCR
80087(g)
800087(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:


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 by having cleaning chemical supplies such as stain remover and oxy clean in an unlocked cabinet located in the bathroom. which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/25/2023
Plan of Correction
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Caregiver removed and locked the stain remover and oxy clean during visit, deficiency cleared during visit.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


LIC809 (FAS) - (06/04)
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