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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200462
Report Date: 04/05/2024
Date Signed: 04/05/2024 06:40:05 PM

Document Has Been Signed on 04/05/2024 06:40 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/
DIRECTOR:		MARCIAL D. JULIANFACILITY TYPE:
740
ADDRESS:26798 CONTESSA STREETTELEPHONE:
(510) 783-5216
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 3DATE:
04/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:40 PM
MET WITH:Belinda Dela Cruz/Staff TIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit for the deficiency observed during investigation of complaint (15-AS-20240327144832), but was not cited on April 4, 2024 LPA learned that the administrator yelled at resident (R1) which during interview, the administrator admitted to yelling when R1 becomes verbally abusive to the caregivers.

On this day, April 5, 2024, LPA met with Belinda Dela Cruz, staff. LPA called and spoke over the phone with Marcial Julian, administrator, and informed the reason for visit.

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 additional civil penalty.



Deficiency and plan and proof of correction were discussed with the administrator over the phone, Administrator authorized Belinda Dela Cruz to sign and receive this report,

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: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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 04/05/2024 06:40 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/05/2024 at 06:00 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: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Administrator to do the following, and submit proof by 4/19/24:
1. Read the Regulations and submit self-certification.
2. In-service the staff.
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-This requirement is not met as evidenced by:
-Based on interview, the licensee did not comply with the section above in yelling at the resident which posed a potential personal rights risk to person 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: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024


LIC809 (FAS) - (06/04)
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