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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 11/13/2025
Date Signed: 11/13/2025 05:37:58 PM

Document Has Been Signed on 11/13/2025 05:37 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:COLONIAL ACRES RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200664
ADMINISTRATOR/
DIRECTOR:		MAGALLONES, ADELIZA RFACILITY TYPE:
740
ADDRESS:18905 STANDISH AVENUETELEPHONE:
(510) 276-0939
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 20CENSUS: 18DATE:
11/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:John Ronald Olivarez/LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On this day, November 13, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Maria Dolores Floriza, and informed the reason for visit. John Ronald Olivarez, licensee, arrived at around 10:56 am. Licensee left at around 4:30 pm.

LPA started inspection with Maria Dolores Floriza and continued with licensee. LPA inspected the kitchen, dining area, living/tv room, common areas, bathrooms and staff room. LPA randomly selected 5 residents rooms for inspection. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.



Hot water temperature in lavatory in one of the resident's rooms was tested. Fire extinguishers were observed fully charge with tags showed serviced September 23, 2025. Disaster drill records reviewed.

LPA reviewed 5 staff and 5 residents files, and interviewed 1 resident. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders. Facility does not handle residents' cash resources.

Copies of the following updated/current documents were obtained on this same day:
1. LIC610E Emergency Disaster Plan (9 pages)
2. $3M Liability insurance certificate

....continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/13/2025
NARRATIVE
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Licensee to submit copies of the following updated documents by November 27, 2025:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report

The following deficiencies were observed, cited from Title 22 California Code of Regulations, and listed on 809Ds:
-at 10:45 am and 11:26 am, front and back entrance/exit doors with locks operable with code.
-at 11:00 am, resident's medication in the refrigerator.
-at 11:02 am to 11:04 am, knives, kitchen shears, razor, lighter in kitchen drawers without locks.
-at 11:05 am, knives and cleaning agents in unlocked kitchen cabinets and Vit D3 on kitchen counter.
-at 11:23 am, loose light switch cover in one the residents' rooms.
-at 11:25 am, hot water temperature at 121.3 degrees Fahrenheit.
-at 11:27 am, dowels in another entrance/exit door.
-at 11:30 am, unlocked utility room where cleaning supplies are kept.
-at 11:40 am, 2 in one smoke/carbon monoxide detector not working due to no battery.
-at 12:30 pm, facility does not conduct disaster drill every quarter; records showed last conducted 01/2025 and 04/2025.
-at 1:25 pm and 1:50 pm, staff (S2 and S5) CPR/First Aid/AED certificates expired 11/11/25.
-at 1:35, to 1:55 pm, staff, S3 & S4, do not have the required total 40 hours required training for 2024 and 2025 respectively. No TB test and LIC503 Health Screening on file.
-at 2:30 pm, residents, R1 and R2, half bed rails have no doctor's order on file.
-at 2:40, residents, R2 and R3, Physician's Reports/medical assessments are over a year old.
-at 2:50 pm, resident, R4, LIC625 Appraisal/Needs and Services Plan is more than 2 years old.
-at 3:25 pm, resident, R5, has doctor's order for a medication to be administered daily but facility does not have this medication. Facility does not have LIC622 Centrally Stored Medication and Destruction for all the medications received by the facility nor have complete record for medications administered.

A $500.00 immediate civil penalty is assessed for deficiency section 87203 and $250.00 each for repeat violations of the following sections: 87309(a); 87303(a); 87303(e)(2); 1569.695(c); 87565(a)(4); 87608(a)(3). Failure to submit proof of corrections by plan of correction due dates may result in addtional civil penalties.
....continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 11/13/2025 05:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/13/2025 at 03:45 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: COLONIAL ACRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in carbon monoxide not working due to no battery which poses an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 11/14/2025
Plan of Correction
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Corrected.
Licensee put battery while LPA was at the facility.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 the following which pose an immediate safety and/or personal rights risk to persons in care: unlocked knives, kitchen shears, lighter, razor, cleaning agents in the kitchen.
THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD.
POC Due Date: 11/14/2025
Plan of Correction
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Staff removed and locked all the items.
In addition, licensee to in-service the staff and stated he will have lock installed on the kitchen drawers. Copy of in-service and pictures to be submitted by 11/14/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 11/13/2025 05:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/13/2025 at 03:45 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: COLONIAL ACRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

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 inunlocked utility room where cleaning supplies are kep which poses an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 11/14/2025
Plan of Correction
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Licensee locked the room.
In addition, licensee to in-service the staff.
Type A
Section Cited
CCR
87465(h)(1)(C)

87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications ........(1) Medications shall be centrally stored........
(C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in medication on the kitchen counter and resident's medications unlocked in the refrigerator which pose an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 11/14/2025
Plan of Correction
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Staff locked the items.
Licensee to in-service the staff and submit proof by 11/14/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 11/13/2025 05:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/13/2025 at 03:45 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: COLONIAL ACRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in loose light switch cover in resident's room which poses a potential safety and/or personal rights risks to persons in care.
THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD.
POC Due Date: 11/27/2025
Plan of Correction
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Licensee to have the switch cover fixed and submit picture by 11/27/25.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 in hot water temperature at 121.3 degrees Fahrenheit which poses a potential health and/or personal rights risks to persons in care.
THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD.
POC Due Date: 11/27/2025
Plan of Correction
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2
3
4
Licensee to have the water temperature adjusted to a temperature within Regulations range and submit proof by 11/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 11/13/2025 05:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/13/2025 at 03:45 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: COLONIAL ACRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in R2 and R3's medical assessments (Physician's Report) over a year old which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
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2
3
4
Licensee to have a medical assessment schedule for R2 and R3 and submit copies of LIC602A by 11/27/25.
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above in R4's LIC625 Appraisal/Needs and Services Plan more than 2 years old which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
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2
3
4
Licensee to have the re-appraisal performed and submit copy of LIC625 by 11/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 11/13/2025 05:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/13/2025 at 03:45 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: COLONIAL ACRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not conducting drills every quarter which poses a potential safety and/or personal rights risks to persons in care.
THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD.
POC Due Date: 11/27/2025
Plan of Correction
1
2
3
4
Licensee to have drills conducted and submit copy by 11/27/25,
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements – General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in staff (S2 and S5) certificates expired which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
1
2
3
4
Licensee to have S2 and S5 register for training and submit copies of certificates by 11/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 11/13/2025 05:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/13/2025 at 04:28 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: COLONIAL ACRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician… A signed statement shall be obtained from each volunteer affirming that he/she is in good health……
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in S3 and S4 not having TB test and LIC503 Health Screening on file which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
1
2
3
4
Licensee to have the staff undergo health screening and submit proof by 11/27/25.
Type B
Section Cited
CCR
1569.625(b)(1)
§1569.625 Staff training; legislative findings; contents : (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in S3 & S4 not have the required total 40 hours required training which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
1
2
3
4
Licensee to have the staff complete training and submit proof by 11/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 11/13/2025 05:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/13/2025 at 04:49 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: COLONIAL ACRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)(AtoF)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A)to(F).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above for not having LIC622 Centrally Stored Medication and Destruction for all the medications received by the facility nor have complete record for medications administered for R5 which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
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2
3
4
Licensee to have the records completed and submit proof by 11/27/25.
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in not having doctor's orders for R1 and R2's half bed rails which pose a potential health, safety andor personal rights risks to persons in care.
THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD.
POC Due Date: 11/27/2025
Plan of Correction
1
2
3
4
Licensee to obtain doctor's orders and submit copies by 11/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 10 of 12
Document Has Been Signed on 11/13/2025 05:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/13/2025 at 04:53 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: COLONIAL ACRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic

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 in Installing a door hardware operable with code in 2 entrance/exit doors and having dowels in the other entrance/exit door
which poses an immediate health, safety or personal rights risk to persons in care.
A $500.00 civil penalty is assessed.
POC Due Date: 11/14/2025
Plan of Correction
1
2
3
4
Corrected.
Licensee removed and replaced the door hardwares and replaced with a 'no-knowledge' type and removed the dowels while LPA was at the facility.
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having one of R5's prescribed medications which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 11/14/2025
Plan of Correction
1
2
3
4
Licensee to have the medication obtained and submit picture by 11/14/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 11 of 12
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: 11/13/2025
NARRATIVE
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Deficiencies and plan and proof of corrections were discussed with licensee over the phone, and authorized Maria Dolores Floriza.

Exit interview conducted. Appeal Rights, LIC421IM, LIC421FC Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC809 (FAS) - (06/04)
Page: 12 of 12