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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200164
Report Date: 08/15/2022
Date Signed: 08/16/2022 08:23:10 AM

Document Has Been Signed on 08/16/2022 08:23 AM - 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:HAYWARD HOLY INFANT RES. CARE FAC. IIFACILITY NUMBER:
019200164
ADMINISTRATOR:SIMPORIANA P. JUGARAPFACILITY TYPE:
735
ADDRESS:1836 FLORIDA STREETTELEPHONE:
(510) 732-5605
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 6DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH: Simporiana 'Bing' Jugarap/Administrator TIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with staff, Lolita Gevana, and informed the reason for visit. LPA called and spoke with Simporiana 'Bing' Jugarap, administrator, who arrived after several minutes. LPA also met with other staff, John Jugarap, Imelda Mapalo, Eleuterio Mapalo, Jose Joy Peneranda and Bryan Ray Peneranda.

Facility has LIC808 Mitigation Plan on file. Administrator submitted the facility's new Infection Control Plan which LPA received on May 12, 2022. All staff were fit tested for N95 respirators on April 6, 2022..

LPA started the inspection with John Jugarap, Jose Joy Peneranda and Bryan Ray Peneranda, and later joined by Simporiana Jugarap. LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathroom, garage, front, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station located near the entrance with visitor's log, hand sanitizer and no touch thermometer. Surgical masks, disposable gloves and antigen test kits are readily available at the screening station. Visitor's temperature, and symptom and vaccination record checks are done at entry for visitors and staff. Residents and staff are screened for COVID-19 symptoms and temperature is checked and recorded daily. COVID-19 signages were observed posted all throughout the facility. Supplies of PPEs were checked.

Hot water temperature at the common bathroom was tested and measured at 110.5 degrees Fahrenheit. Fire extinguisher checked and observed fully charge with tag showed serviced February 28, 2022. First aid kit was observed complete with manual.

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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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 3
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: HAYWARD HOLY INFANT RES. CARE FAC. II
FACILITY NUMBER: 019200164
VISIT DATE: 08/15/2022
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LPA observed the following:
1. Trash bin's lid on the common area is not touch free.
2. No paper towel holder in the common bathroom.

Administrator to submit the following updated documents by August 29, 2022:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety bond coverage

No deficiency cited during today's inspection.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
LIC809 (FAS) - (06/04)
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