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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200471
Report Date: 11/11/2022
Date Signed: 11/11/2022 12:19:12 PM

Document Has Been Signed on 11/11/2022 12:19 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:HEIWA GROWTH HOUSEFACILITY NUMBER:
019200471
ADMINISTRATOR:YUKA ONOFACILITY TYPE:
735
ADDRESS:2686 HILLCREST AVENUETELEPHONE:
(510) 677-6889
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 6DATE:
11/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Marilou Moise, CaregiverTIME COMPLETED:
12:30 PM
NARRATIVE
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On 11/11/2022 at 10:10AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Marilou Moise, Caregiver, and explained the purpose of the visit. Administrator, Lilibeth Toco arrived at 10:55AM.

Upon entry, LPA's temperature was not checked and there was not a mask sign on front door. LPA observed hand sanitizer and COVID signs at after entering front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. All hand washing stations were equipped with soap. There were not any hand washing signs posted in bathrooms or kitchen. Hot water temperature in the shared clients’ bathroom was measured at 115.5 degrees Fahrenheit. Fire extinguisher purchased on 7/17/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods. LPA observed facility home heater is broken and facility is cold inside. Staff using portables to heat home.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the mitigation plan on file. LPA observed PPE and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/11/2022
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: HEIWA GROWTH HOUSE
FACILITY NUMBER: 019200471
VISIT DATE: 11/11/2022
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Continued from LIC809.

The following forms are to be updated and submitted to CCLD by 11/18/2022:
  • -LIC500 Personnel Report
  • -LIC308 Designation of Administrative Responsibility
  • -LIC601D Emergency Disaster Plan
  • Infection Control Plan

LPA observed the following deficiencies:
  • -At 10:15AM, LPA observed that S2 was working solo with 6 RCEB clients. S3 arrived at 10:35AM.
  • -At 10:20AM, LPA observed that home heater was broken. Facility using portables to heat home and bedrooms.
  • -At 10:25AM, LPA observed 2 pair of scissors on desk in unlocked garage that is being used as an office.
  • -At 10:35AM LPA observed a broken dryer, a chair,a couch, a mattress, and a toilet, and a mattress bed spring in back yard.
  • -At 10:40AM, LPA observed screens on ground in back yard from two (2) windows #3 and #4.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 11/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2022
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 11/11/2022 12:19 PM - It Cannot Be Edited


Created By: Laura Hall On 11/11/2022 at 11:33 AM
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: HEIWA GROWTH HOUSE
FACILITY NUMBER: 019200471

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings 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
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Based on observation, the licensee did not comply with the section cited above in having 2 pair of scissors accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2022
Plan of Correction
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Caregiver immediately placed both pair of scissors in drawer and locked garage/office door to make scissors inaccessible. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/11/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/11/2022 12:19 PM - It Cannot Be Edited


Created By: Laura Hall On 11/11/2022 at 11:41 AM
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: HEIWA GROWTH HOUSE
FACILITY NUMBER: 019200471

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(a)
80088 Furniture, Fixtures, Equipment, and Supplies

(a) A comfortable temperature for clients shall be maintained at all areas.

(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not having a working heater for facility and portables were not on during visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Administrator agreed to get quotes and schedule for heater to be fixed, and submit information to CCLD by POC date.
Type B
Section Cited
CCR
8088(b)
80088 Furniture, Fixtures, Equipment, and Supplies

(b) All window screens shall be in good repair and be free of insects, dirt and other debris

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 in having screens off 2 bedroom windows which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Administrator agreed to replace window screens on bedrooms number #3 and #4, and submit photo to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/11/2022


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 11/11/2022 12:19 PM - It Cannot Be Edited


Created By: Laura Hall On 11/11/2022 at 11:46 AM
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: HEIWA GROWTH HOUSE
FACILITY NUMBER: 019200471

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85065.5(a)
85065.5 Day Staff-Client Ratio

(a) Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met:

(1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.

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 in having sufficient staffing. LPA observed one staff present which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Administrator agreed to submit an updated staff scheduled for the month of November to CCLD by POC date.
Type B
Section Cited
CCR
80087(c)
80087 Buildings and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 in having a couch, chair, toilet, dryer mattress, and mattress spring in back yard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Administrator agreed to having all items removed from back yard and submit a photo to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/11/2022


LIC809 (FAS) - (06/04)
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