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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200462
Report Date: 01/19/2022
Date Signed: 01/19/2022 03:00:04 PM

Document Has Been Signed on 01/19/2022 03:00 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:JULIAN FAMILY CAREHOMEFACILITY NUMBER:
019200462
ADMINISTRATOR:MARCIAL D. JULIANFACILITY TYPE:
740
ADDRESS:26798 CONTESSA STREETTELEPHONE:
(510) 783-5216
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 5DATE:
01/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marcial Julian/Licensee-AdministratorTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with staff, Melinda delos Santos and Belinda dela Cruz and informed the purpose of visit. LPA requested to call Marcial Julian, licensee-administrator, who arrived after several minutes.

Facility has an approved LIC808 COVID-19 Mitigation Plan. Staff were fit tested for N95 respirator.

LPA started inspection with delos Santos and continued with Julian. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, surgical masks and no touch temperature probe. Visitors are screened for symptoms and temperature and recorded on visitor's log. Routine symptom screening (+/-) temperature and symptom checks are done for all staff and residents, and recorded daily. Trash bins were observed with pedal operated lids. Centrally stored PPEs inspected. Facility has updated visitor's poster posted on entrance door. Facility has COVID-19 signages/posters.

Fire extinguisher was observed fully charge; however, tag showed serviced October 12, 2020. The 2 in 1 smoke and carbon monoxide detector was observed operational. First aid kit inspected and observed complete with manual.

LPA observed the following:
1. Expired pineapple juice, Ranch salad dressing, Thousand Island salad dressing, orange juice, mayonnaise, V8 Splash juice.
2. Supply of disposable gowns not sufficient for 30 days for 4 staff.

LPA received on this day a copy of proof of $3M liability insurance coverage.

......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
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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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: JULIAN FAMILY CAREHOME
FACILITY NUMBER: 019200462
VISIT DATE: 01/19/2022
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LPA requested for the following updated documents to be submitted by February 2, 2022:
1. LIC500 Personnel Report
2. LIC610E Emergency Disaster Plan

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Marcial Julian.

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: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/19/2022 03:00 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/19/2022 at 02:22 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: JULIAN FAMILY CAREHOME
FACILITY NUMBER: 019200462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(a)

87555 General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health risk to persons in care. LPA observed expired pineapple and orange juices, Ranch and Thousand Island salad dressings, mayonnaise and V8 Splash juice.
POC Due Date: 01/20/2022
Plan of Correction
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Staff throw away the expired items.
Licensee to do the following and submit proof by 1/20/2022:
1. Have all the food supplies checked.
2. In-service the staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 01/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2022


LIC809 (FAS) - (06/04)
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