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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200520
Report Date: 03/07/2024
Date Signed: 03/07/2024 12:16:15 PM

Document Has Been Signed on 03/07/2024 12:16 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:JAYAR HOMEFACILITY NUMBER:
019200520
ADMINISTRATOR:ALCANTARA, MARIAFACILITY TYPE:
735
ADDRESS:576 JAYAR PLACETELEPHONE:
(510) 324-8343
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
03/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kevin Braud/Irene MonteclarTIME COMPLETED:
12:45 PM
NARRATIVE
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On this day at around 10:30 am, LPA Luisa Fontanilla arrived unannounced to deliver findings of the investigation conducted by the Department related to a questionable death of a client while in care. LPA met with Kevin Braud and Irene Monteclar.

During the course of investigation, the Department conducted interviews and record reviews.

On 11/22/2022, LPA Leslie Ibo conducted a case management visit in connection with a self-reported questionable death of a client. On 11/28/2022, the incident was referred to and investigated by Investigations Branch (IB).

Based on records review conducted, C1's primary doctor signed off on C1's death certificate with the cause of death as Aspiration Pneumonia-Saliva Dysphagia. However, doctor believes C1's history of heart disease could have also been a factor. C1's progress notes state C1 has a history of pneumonia, dysphagia and was on a pureed diet. The doctor stated no concerns with the facility's care plan.

In regards to the suction machine used for C1, C1's doctor believes the facility already had the suction machine in the home, possibly from a previous resident, and they began to use it on C1. C1 passed away on 11/17/2022 and the facility requested an official document of approval for the usage of the suction machine on C1 on 11/22/2022. The doctor signed off on this request and approved it for it having been used previously on C1. Staff do not need training to use the suction machine if they plan on using it only in the mouth of the patient. However, if the tube goes deeper down into the trachea, then only skilled nursing staff can use it. In C1's case, the doctor believes staff were only using it in the general mouth area and they did not go further down.

continuation on Lic 809C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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 4
Document Has Been Signed on 03/07/2024 12:16 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/07/2024 at 11:11 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: JAYAR HOME
FACILITY NUMBER: 019200520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2024
Section Cited
CCR
80091(a)

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80091(a) Prohibited Health Conditions
(a) In adult CCFs clients who require health services or have a health condition including, but not limited to, those … shall not be admitted or retained.
This requirement is not met as evidenced by:
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The Administrator will conduct inservice with all staff on restricted and prohibited conditions and submit proof to CCL by POC date.
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 Based on interviews conducted, facility retained C1 who needed suctioning on an as needed basis without an approved exception which poses an immediate threat to the health and safety of clients under care.
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Type A
03/11/2024
Section Cited
CCR80065(a)

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80065(a) Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
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By POC date, the Administrator will conduct in service with all staff emergency procedures and submit proof to CCL.
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This requirement is not met as evidenced by:
Based interviews and record reviews conducted, S10 performed suctioning on C1 but there is no proof of training on file.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


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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: JAYAR HOME
FACILITY NUMBER: 019200520
VISIT DATE: 03/07/2024
NARRATIVE
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Based on investigation conducted by the department, staff 10 (S10) found Client 1 (C1) unresponsive and with no pulse on 11/17/2022 at 0500 hours. The last time S10 saw C1 responsive was at 0300 hours. S10 is trained in First Aid and CPR and knows that if there is an emergency, S10 will contact 911 immediately. S10 stated S10 got nervous and did not call 911 or attempted to give first aid/CPR. Hayward Fire Department dispatch records show the call went out at 0623 hours.

Upon Hayward Fire Department's arrival to the facility, they found C1 with rigor in the jaw and declared dead. Staff on duty waited for the House Manager to arrive at the facility at around 0600 hours reported R1’s condition. The 911 call was recorded at 6:23 am at the Hayward Fire Department.

Based on interviews and record reviews conducted, the facility:

1. retained C1 who needed suctioning on an as needed basis without an approved exception

2. allowed untrained staff to use suction machine on C1

3. staff member failed to seek medical attention in a timely manner

Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D). Failure to correct or repeat violations within 12 month period may result in civil penalties.

Exit interview was conducted with Braud and Appeal Rights was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/07/2024 12:16 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/07/2024 at 11:34 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: JAYAR HOME
FACILITY NUMBER: 019200520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2024
Section Cited
CCR
80075(a)

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80075(a) Health Related Services
80075(a) Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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The Administrator will conduct in person First aid and CPR with all staff and submit proof to CCL by POC date.
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This requirement is not met as evidenced by:
Based on interviews conducted, S10 found C1 unresponsive but failed to perform CPR or call 911 which poses an immediate health and safety risk to clients under 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
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