019200664-11-9-2021-15-AS-ADEO-C8M5T8-20211109191355

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 11/09/2021
Date Signed: 11/09/2021 07:14:06 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:	COLONIAL ACRES RESIDENTIAL CARE HOME		FACILITY NUMBER:	019200664
ADMINISTRATOR:	SARAH MAY BALINGIT		FACILITY TYPE:	740
ADDRESS:	18905 STANDISH AVENUE		TELEPHONE:	(510) 276-0939
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	20	CENSUS: 17	DATE:	11/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Sarah Balingit/Administrator		TIME COMPLETED:	06:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with John Ronald Olivarez, licensee. LPA also met with Celeste Olivarez, facility staff/consultant. LPA later met with Sarah Balingit, administrator. LPA informed the purpose of visit. Facility has completed COVID-19 mitigation plan and submitted to Community Care Licensing (CCL). LPA observed a hand sanitizer and a box of disposable gloves located close to the entrance door and visitor's log close to the office. Staff were observed wearing mask. Supplies of centrally stored PPEs inspected. LPA inspected the facility inside out with Sarah. LPA randomly selected 5 residents and staff rooms for inspection. LPA also inspected 3 common bathrooms, staff bathroom, dining area, kitchen, front and backyard. There were at least 7 days of nonperishable and 2 days of perishable food supplies.. Fire extinguishers were observed fully charge and tags showed serviced August 2, 2021. Hot water temperature in the 1 of the bathroom sinks was tested and measured at 118.4 degrees Fahrenheit. LPA observed the following: 1. Three bedrooms inside the staff room. Each of these rooms have door and permanent walls. 2. No COVID-19 signages through out the facility. No hand washing posters in the kitchen and bathroom sinks. No 6 feet physical distancing signs. 3. No visitor and no "Wear mask" posters on the entrance door. ....continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

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: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
	VISIT DATE: 11/09/2021

NARRATIVE

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4. Trash cans without lids in all 3 bathrooms and trash can's lid in the kitchen not "touch free".
5. Supplies of N95 respirators and surgical masks not sufficient for 30 days. No disposable gowns and face shields.
6. Staff were not fit tested for N95 respirators.

Administrator to submit the following updated documents to CCL by November 23, 2021:
1. LIC500 Personnel Report
2. LIC610E Emergency Disaster Plan
3. Proof of $3M liability insurance

LPA reminded that the annual fee is due by November 16, 2021.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). A $500.00 civil penalty is assessed for section 87202(a) and will continue for $100.00/day until corrected.

Deficiency and plan and proof of correction were discussed with Sarah Balingit.

Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

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: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by adding 3 bedrooms inside the staff rooms. License failed to submit updated facility sketch so CCL can request for fire safety inspection. This poses an immediate safety risk to persons in care. A $500.00 civil penalty is assessed.
	POC Due Date: 11/10/2021
	Plan of Correction
1 2 3 4	Administrator to submit the following by November 10, 2021: 1. Updated facility sketch showing the follwing: exit doors and windows; use and dimension of each room; number of residents in each of resident's room; utility shut off locations. 2. LIC9054 Local Fire Inspection Authority Information

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

LIC809 (FAS) - (06/04)

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