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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200148
Report Date: 07/20/2022
Date Signed: 07/20/2022 05:27:39 PM

Document Has Been Signed on 07/20/2022 05:27 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:
07/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Cecilia Laurente/Staff TIME COMPLETED:
05:30 PM
NARRATIVE
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During the course of investigation of a complaint (15-AS-20200421134126), and when Licensing Program Analyst (LPA) Delmundo verified, Beth Nunez, administrator, stated she did not submit an incident report nor an SOC341 and/or reported to Community Care Licensing when she learned about the alleged hitting incident.

On this day, July 20, 2022, LPA spoke and discussed with Beth Nunez, over the phone the above and the Title 22 Reporting Requirement.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Beth Nunez who authorized Cecilia Laurente to sign and receive this report.

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: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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Document Has Been Signed on 07/20/2022 05:27 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/20/2022 at 05:07 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: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/03/2022
Section Cited
CCR
80061(d)

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80061Reporting Requirements
(d) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and ..............
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Administrator to do the following and submit proof by 8/03/022:
1. Read the Regulations.
2. In-service the staff.
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Institutions Code Section 15630(b)(1).
-This requirement is not met as evidenced by:

-Based on interview, the licensee did not comply with the section above by not reporting the alleged hitting incident.
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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: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


LIC809 (FAS) - (06/04)
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