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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200164
Report Date: 08/15/2023
Date Signed: 08/15/2023 07:54:05 PM

Document Has Been Signed on 08/15/2023 07:54 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: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:
08/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Simporiana 'Bing' Jugarap/AdministratorTIME COMPLETED:
08:00 PM
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On this day, August 15, 2023, at 3:25 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Imelda Mapalo and Lolita Gevana, and informed the reason for visit. LPA called and spoke with Simporiana 'Bing' Jugarap, administrator, who gave permission to have Imelda Mapalo to be with LPA in touring the facility. Administrator arrived after about 20 minutes. LPA also met with other staff, Bryan Ray Penaranda.

Administrator submitted an updated Infection Control Plan on August 3, 2023.

LPA toured the facility inside out. LPA inspected the kitchen, dining area, living room, bedrooms, bathroom, garage, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Drawer where sharps are kept was observed with lock. Cleaning supplies in cabinets with lock.

Fire extinguisher was observed fully charge with tag showed serviced February 22, 2023. Carbon monoxide and smoke detectors were tested and observed in operating condition. Hot water temperature in the ensuite bathroom was tested, and measured at 114.6 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed last conducted August 12, 2023.

LPA reviewed 5 staff and 5 residents files, and interviewed 2 staff and 2 residents. Medications checked and compared with doctor's orders and records. Residents' P&I inspected, and reconciled with records.


.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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: HAYWARD HOLY INFANT RES. CARE FAC. II
FACILITY NUMBER: 019200164
VISIT DATE: 08/15/2023
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Administrator to submit the following updated/current documents by August 29, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Surety Bond coverage

No deficiency cited during today's visit.

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

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC809 (FAS) - (06/04)
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