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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200395
Report Date: 07/02/2024
Date Signed: 07/02/2024 08:49:57 PM

Document Has Been Signed on 07/02/2024 08:49 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:PECO CARE HOMEFACILITY NUMBER:
019200395
ADMINISTRATOR/
DIRECTOR:		JEAN B. RODRIGUEZFACILITY TYPE:
735
ADDRESS:34914 PECO STREETTELEPHONE:
(510) 589-9419
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
07/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:15 PM
MET WITH:Jean Rodriguez/Administrator
and Rashpal Wairaich/Licensee 		TIME VISIT/
INSPECTION COMPLETED:
08:50 PM
NARRATIVE
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While conducting investigation of a complaint (Complaint Control # 15-AS-20240627081442), Licensing Program Analyst (LPA) Delmundo learned, obtained information and observed the following:
1. Staff (S1) who has fingerprint clearance on file is not associated to this facility.
2. Residents LIC622 Centrally Stored Medication and Destruction Records do not have dates medications were started.
3. Some of resident's (R1) medications and all of resident (R2) medications do not have doctor's order on file,

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 licensee and 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: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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 3
Document Has Been Signed on 07/02/2024 08:49 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/02/2024 at 07:30 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: PECO CARE HOME
FACILITY NUMBER: 019200395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2024
Section Cited
CCR
80075(b)(6)(D)

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80075 Health Related Services
(b) Clients shall be assisted as needed
(6)(D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file...
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Corrected.
Administrator obtained doctor's orders while LPA was at the facility.
In addition. administrator to ensure all residents medications have doctor's orders on file.
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.....blank, maintained in the client's file...
-This requirement is not met as evidenced by:
-Based on records review, the licensee did not comply with the section above for not having doctor's order for some of R1 and all of R2's medications which posed an immediate risks to persons in care.
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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: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/02/2024 08:49 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/02/2024 at 07:40 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: PECO CARE HOME
FACILITY NUMBER: 019200395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2024
Section Cited
CCR
80019(e)(3)

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80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review .......shall prior to working, residing or volunteering in a licensed facility:
(3) Request a transfer of a criminal record clearance as specified in Section 80019(f)...
-This requirement is not met as evidenced by:
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Administrator to have the staff associated and submit proof by 7/16/24.
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-Based on record review and interviews, the licensee did not comply with the section above in S1 not associated to this facility which poses a potential safety risk to persons in care.
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Type B
07/16/2024
Section Cited
CCR80070(a)

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80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

-This requirement is not met as evidenced by:
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Administrator to complete all the LIC622s and submit self-certification by 7/16/24.
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-Based on records review, the licensee did not comply with the section above for not recording on LIC622 when R1 and R2's medicaitons were started which pose a potential health and/or personal rights risks to persons in care.
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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: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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