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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200148
Report Date: 02/28/2025
Date Signed: 02/28/2025 06:23:31 PM

Document Has Been Signed on 02/28/2025 06:23 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/
DIRECTOR:		BETH NUNEZFACILITY TYPE:
735
ADDRESS:27481 ORLANDO AVETELEPHONE:
(510) 785-9215
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Ireneo 'Rene' Pascual and Angeline Cuevas, Staff,
and Jordan Deo Nunez. Assistant Administrator		TIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On this day, February 28, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with staff, Ireneo 'Rene' Pascual and Angeline Cuevas, and informed the reason for visit. LPA called and spoke over the phone with Beth Nunez, administrator (ADM). ADM stated she can not come to the facility, and authorized to have Ireneo Pascual to be with LPA during inspection and sign and receive this report. Jordan Deo Nunez, assistant administrator (AADM) arrived at around 4:15 pm.

LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms, garage, front, side and backyard. Food were inspected and observed supplies of 2 days of perishables and 7 days of non-perishables.

Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in the ensuite bathroom was tested, and measured at 113.9 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed last conducted January 20, 2024. Fire extinguisher checked, observed fully charge with tag showed serviced February 24, 2025.

LPA reviewed 5 staff and 5 residents files. Medications checked, and compared with records and doctor's orders. Residents' P&I checked and compared with last recorded balance.

LPA observed the following:
-at 2:30 pm, hole on the wall and dirty wall in resident's (R1) room.
-at 2:36 pm, dusty electric fan in resident's (R2 and R3) shared room.
-at 2:40 pm, dusty heater by the hallway near the dining area.
-at 5:05 pm, resident's (R2) medications do not have doctor's order on file.
.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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: 02/28/2025
NARRATIVE
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Administrator to submit updated/current copies of the following by March 14, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
3. Proof of Surety Bond coverage

Deficiencies are 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.

Deficiencies and plan and proof of corrections were discussed with AADM in the presence of the Ireneo Pascual.

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: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/28/2025 06:23 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2025 at 05:22 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: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in resident's (R2) medications do not have doctor's order on file which pose an immediate health and/or personal rights risk to person in care.
POC Due Date: 03/01/2025
Plan of Correction
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Assistant administrator stated he'll obtain doctor's order. Copies to be submitted by 3/01/25.

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: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2025 06:23 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2025 at 05:22 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: 02/28/2025

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 health and/or personal rights risks to persons in care: hole on the wall and dirty wall in resident's (R1) room; dusty electric fan in resident's (R2 and R3) shared room; dusty heater
POC Due Date: 03/14/2025
Plan of Correction
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Assistant administrator to do the following and submit pictures by 3/14/25:
1. Have the wall cleaned and repaired. .
2. Have the electric fan and heater cleaned.
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: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


LIC809 (FAS) - (06/04)
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