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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200471
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:57:37 PM

Document Has Been Signed on 11/19/2024 02:57 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HEIWA GROWTH HOUSEFACILITY NUMBER:
019200471
ADMINISTRATOR/
DIRECTOR:		YUKA ONOFACILITY TYPE:
735
ADDRESS:2686 HILLCREST AVENUETELEPHONE:
(510) 677-6889
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 6DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Assistant Administrator Lilibeth TocoTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 11/19/2024 at 12:10 PM, Licensing Program Analysts (LPAs) D. Doidge and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with, Caregiver Phillip Moise and explained the purpose of the visit. Assistant Administrator, Lilibeth Toco arrived at 1:30PM.

LPAs toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, common area and backyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 68 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 118 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 06/15/2024. Emergency disaster drill is conducted annually, last conducted on 04/01/2024. No Infection Control Plan posted. First aid kit was observed to be complete. LPAs reviewed six (6) resident records and three (3) staff records.

LPAs observed no Infection Control Plan on file.



The above deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22 and/or Health Safety Code failure to correct deficiencies by POC dates may result in additional civil penalties.

Exit interview conducted and a copy of this report and appeals rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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 11/19/2024 02:57 PM - It Cannot Be Edited


Created By: David Doidge On 11/19/2024 at 02:33 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: HEIWA GROWTH HOUSE
FACILITY NUMBER: 019200471

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:

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 as there is no Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2024
Plan of Correction
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Administrator to provide a copy of the Infection Control Plan to LPA by POC date.
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:David Doidge
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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