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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200544
Report Date: 07/30/2020
Date Signed: 07/30/2020 03:12:56 PM

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:AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
019200544
ADMINISTRATOR:ALBERT LEANOFACILITY TYPE:
740
ADDRESS:23652 NEVADA ROADTELEPHONE:
(510) 314-0807
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 5DATE:
07/30/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Manuel 'Manny' Jimeno/House ManagerTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted a case management televisit regarding the death of a resident reported to LPA by House Manager Manuel Jimeno. During case management televisit by LPA on June 24, 2020, Mr. Jimeno indicated that resident (R1) passed away around first week of July and that the death report was faxed over to Community Care Licensing (CCL).

On this day, July 30, 2020, LPA reviewed e-faxes documents; however CCL did not receive R1's death report. LPA requested Mr. Jimeno to resend which LPA received on this same day. Death report indicated R1 was at normal state when seen by staff at 5:00 am on July 2, 2020. When staff was to do morning care at 7:20 am, R1 was found unresponsive. R1 has POLST on file. R1 was not on hospice.

LPA also conducted a video conference call with Helen Macatangay on this same day and discussed the above.

LPA conducted interviews. LPA requested Mr. Jimeno to submit to LPA a copy of POLST and LIC601 Identification and Emergency Information on this same day.

Deficiency is cited from Title 22 California Code of Regulations. Failure to submit proof of correction by plan of correction due date along with the LIC9098 Proof of Correction form and any repeat violation within twelve month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Ms. Macatangay.

Exit interview conducted.

Appeal Rights, copy of this report and LIC9098 form provided via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020
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: AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 019200544
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2020
Section Cited

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87469 Advanced Directives and Requests Regarding Resuscitative Measures: (c) If a resident who has an advance directive and/or request regarding resuscitative measures form .........facility staff shall do one of the following: (1) Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to responding
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emergency medical personnel and identify the resident as the person to whom the order refers.
-Based on document review and interviews, the licensee did not comply with the Regulation when staff failed to call 9-1-1.
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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: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2020
LIC809 (FAS) - (06/04)
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