019200664-12-20-2024-15-AS-ADEO-DC65AQ-20241220184732

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 12/20/2024
Date Signed: 12/20/2024 06:47:38 PM

Document Has Been Signed on 12/20/2024 06:47 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 HOME		FACILITY NUMBER:	019200664
ADMINISTRATOR/ DIRECTOR:	MAGALLONES, ADELIZA R		FACILITY TYPE:	740
ADDRESS:	18905 STANDISH AVENUE		TELEPHONE:	(510) 276-0939
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY: 20	TOTAL ENROLLED CHILDREN: 0	CENSUS: 13	DATE:	12/20/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	04:10 PM
MET WITH:	Mary Eileen Legados/Administrator and John Ronald Olivarez/Licensee		TIME VISIT/ INSPECTION COMPLETED:	06:50 PM

NARRATIVE

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On this day, 12/20/24, at 4:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management resulting from the investigation of a complaint (15-AS-20220927100258) by the Department. LPA met with Mary Eileen Legados, administrator (ADM), and informed the purpose of visit. John Ronald Olivarez, licensee, arrived after about an hour.

During investigation, the Department observed the following:
1. Resident's (R1) LIC602A Physician's Report dated 1/25/22 indicated the following: non-ambulatory and bedridden; contractures on lower & upper extremities; advanced frontotemporal dementia; fractured pelvis (unable to rehabilitate). The staff interviewed indicated R1 needs to be repositioned. LIC9020 Register of Facility Clients/Resident was bedridden.
2. LIC602A showed R1 was dependent on others with all activities of daily living (ADLs).
3. R1's LIC9172 Functional Capability Assessment was incompletely filled-up.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil is assessed for deficiency section # 87202(a)(2) and will continue for $100.00/day until corrected.

Deficiencies, plan and proof of corrections and civil penalty were discussed with licensee and ADM.

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

Bennett Fong	TELEPHONE: (510) 622-2621
Alicia Delmundo	TELEPHONE: (510) 286-4201
	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

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 12/20/2024 06:47 PM - It Cannot Be Edited

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: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by...... Prior to accepting or retaining any of the following types of persons.... licensee shall .... obtain an appropriate fire clearance approved by city, county, tor district..... ....(2) Bedridden persons.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/21/2024
	Plan of Correction
1 2 3 4	R1 is no longer at the facility. Administrator to review all residents files and check their ambulatory status. Proof to be submitted by 12/21/24. A $500.00 civil penalty is assessed.

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.

Bennett Fong	TELEPHONE: (510) 622-2621
Alicia Delmundo	TELEPHONE: (510) 286-4201
	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/20/2024 06:47 PM - It Cannot Be Edited

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: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(5) Residents who depend on others to perform all....
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/03/2025
	Plan of Correction
1 2 3 4	Licensee and administrator to read the Regulations and ensure no resident with prohibited health conditions is admitted to the facility. Self-certification to be submitted by 1/03/25.

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.

Bennett Fong	TELEPHONE: (510) 622-2621
Alicia Delmundo	TELEPHONE: (510) 286-4201
	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC809 (FAS) - (06/04)

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