<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200164
Report Date: 08/24/2024
Date Signed: 08/24/2024 04:36:49 PM

Document Has Been Signed on 08/24/2024 04:36 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/
DIRECTOR:		SIMPORIANA P. JUGARAPFACILITY TYPE:
735
ADDRESS:1836 FLORIDA STREETTELEPHONE:
(510) 732-5605
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 4DATE:
08/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Simporiana 'Bing' Jugarap/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, August 24, 2024, at 11:30 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Bryan Ray Penaranda and Romeo Collado, and informed the reason for visit. LPA called and spoke with Simporiana 'Bing' Jugarap, administrator, who arrived around 11:55 a.m.

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

LPA started the inspection with Bryan Ray Penaranda and continued with the administrator. LPA inspected the kitchen, dining area, living room, bedrooms, bathroom, garage, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medication and drawers where sharps are kept were observed with locks.

Fire extinguisher was observed fully charge with tag showed serviced February 18, 2024. Carbon monoxide and smoke detectors were tested and observed in operating condition. Hot water temperature in the common bathroom was tested, and measured at 108.5 degrees Fahrenheit. Facility conducts disaster drills and records showed last conducted June 2, 2024.

LPA reviewed 5 staff and 4 residents files, and interviewed 1 staff and 1 resident. Medications checked and compared with doctor's orders and records. Residents' P&Is checked and compared with last recorded balance.


.......continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2024
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 4
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: 08/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2

LPA observed the following:
-at 11:50 a.m., Vicks vaporub in one of the residents' room.
-at 11:51 a.m., castor oil, acne cream in the ensuite bathroom.
-at 11:53 a.m., screw driver in the drawer in another resident's room.
-at 11:55 a.m., heavily scratched dining floor.
-at 11:56 a.m., pieces of wood in the backyard.
-at 11:57 a.m., shovel in the backyard.

Administrator to submit copies of the following updated/current documents by September 7, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. 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 the administrator.

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: 08/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/24/2024 04:36 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/24/2024 at 04:07 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: HAYWARD HOLY INFANT RES. CARE FAC. II
FACILITY NUMBER: 019200164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in unlocked castor oil, acne cream, Vicks vaporb, screw driver and shovel which pose an immediate health, safety and/or personal rights risks to persons in care.
POC Due Date: 08/25/2024
Plan of Correction
1
2
3
4
Staff locked the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 8/25/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 08/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/24/2024 04:36 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/24/2024 at 04:19 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: HAYWARD HOLY INFANT RES. CARE FAC. II
FACILITY NUMBER: 019200164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in pieces of wood in the backyard and heavily scratched dining area flooring which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 09/07/2024
Plan of Correction
1
2
3
4
Administrator to do the following and submit pictures by 9/07/24:
1. Have the yard cleaned.
2. Sand and seal the flooring,
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 08/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4