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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200164
Report Date: 07/19/2022
Date Signed: 07/19/2022 06:44:39 PM

Document Has Been Signed on 07/19/2022 06:44 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:
07/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Simporiana Jugarap/AdministratorTIME COMPLETED:
06:45 PM
NARRATIVE
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During the course of investigation of a complaint (15-AS-20200312114218), Licensing Program Analyst (LPA) Delmundo learned that resident (R1) sustained bruise at bottom of right eye and right arm back in September 2020. Review of records revealed the facility did not submit incident report.

LPA discussed with Simporiana Jugarap, administrator, the above incident and 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.

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: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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 07/19/2022 06:44 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/19/2022 at 06:10 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: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2022
Section Cited
CCR
80061(b))1)(E)

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80061 Reporting Requirements
(b) Upon the occurrence......In addition, a written report....shall be submitted to the licensing agency within seven days. (1) Events (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
-This requirement is not met as evidence by:
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Administrator to do the following and submit proof by 8/02/022:
1. Read the Regulations.
2. In-service the staff.
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-Based on review of records, the license did not comply with the section above by not submitting incident report when R1 sustained bruises.
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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: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022


LIC809 (FAS) - (06/04)
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