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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 11/14/2024
Date Signed: 11/14/2024 09:32:54 PM

Document Has Been Signed on 11/14/2024 09:32 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: 20TOTAL ENROLLED CHILDREN: 0CENSUS: 13DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:John Ronald Olivarez/LicenseeTIME VISIT/
INSPECTION COMPLETED:
09:35 PM
NARRATIVE
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At 12:30 pm on this day, November 14, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with John Ronald Olivarez, licensee, and informed the reason for visit. LPA also met with staff, Maria Dolores Floriza, Macario Balingit, Jackylen Mendoza and Celeste Olivarez.

LPA toured the facility inside out with licensee. LPA inspected the kitchen, dining area, living/tv room, common areas, staff and laundry room, bathrooms, side and backyard. LPA randomly selected 6 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.



Facility has 2 in 1 carbon monoxide detector that was tested and observed in operating condition. Hot water temperature in the common bathroom was tested. Disaster drill records reviewed. Fire extinguishers were observed fully charge with tags showed serviced September 17, 2024.

LPA reviewed 5 staff and 5 residents files, and interviewed 2 residents. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders. Facility does not handle residents' cash resources.

The following updated/current documents were obtained on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)

Licensee or administrator to submit by November 28, 2024 a copy of $3M Liability insurance certificate.
....continued on 809C (page 2)
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201
DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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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: 11/14/2024
NARRATIVE
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Page 2

The following deficiencies were observed, cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

-at 12:35 pm, the 3 entrance/exit doors with no auditory signals.
-at 12:39 pm, residents medications in 2 refrigerators unlocked.
-at 12:44 pm, cleaning supplies/agents in unlocked cabinet in the kitchen.
-at 12:47 pm, peritoneal cleanser and broken drawer in residents' room.
-at 12:50 pm, wound cleanser in the cabinet under the sink in another resident's room.
-at 12:55 pm, wound dressing, saline solution, grooming kit in the night stand drawer in another resident's room.
-at 1:01 to 1:03 pm, insect killer, wound cleanser, staff medications, liquid laundry soap, Clorox spray in unlocked staff's room.
-at 1:12 pm, water temperature at 127.4 degrees Fahrenheit.
-facility has new administrator who took over the position when Adeliza Magallones resigned in September 13, 2024 and licensee failed to notify the Department.
-at 2:30 pm, records showed disaster drills last conducted July 6 and 9, 2024.
-at 4:00 pm. resident (R2) was discharged back to the facility on 7/2024 with LIC602A Physician's Report indicated stage 3 pressure injury and dependent on others with all activities of daily living (ADLs); however, R2 is able to feed self. LIC625 not updated.
-at 5:00 pm, all 5 resident's half bed rails do not have doctor's order on file.
-at 5:45 pm, resident (R1) doctor's order for Acetaminophen is 650 mg tablet, 2 tablets PRN but the medication in facility's hand is 325 mg tablet, 2 tablet PRN. Has doctor's order for Vascepa but facility does not have this medication. Order for ducosate sodium is 50 mg 1 capsule daily but medication on hand is 100 mg twice daily. Order for Atorvastatin is 20 mg 1 tablet at bedtime but medication on hand is 10 mg 1 tablet at bedtime and facility administers 10 mg. Order for Amlodipine is 5 mg once daily and the medication on hand is 10 mg once daily.

...continued on 809C (page 3)
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 11/14/2024 09:32 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/14/2024 at 07:45 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: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above in hot water at 127.4 degrees Fahrenheit which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee to have the temperature adjusted within Regulations range and submit proof by 11/15/24.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 right risks to persons in care: unlocked kitchen cabinet where cleaning supplies are kept; insect killer, laundry soap, Clorox spray, wound cleanser, staff's medications in unlocked staff room
POC Due Date: 11/15/2024
Plan of Correction
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License locked the items and the staff room.
In addition, licensee and/or administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/15/24.
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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 11/14/2024 09:32 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/14/2024 at 07:45 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: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

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 all 3 entrance/exit doors' auditory signals/device turned off & not working which pose an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Corrected.
Staff fixed and turned on the auditory signals.
Type A
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 health, safety and/or personal rights risk to persons in care: residents medications unlocked in the refrigerator; saline solution, wound and peritoneal cleansers, grooming kit in residents' rooms
POC Due Date: 11/15/2024
Plan of Correction
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Licensee locked all the items.
In addition, licensee and/or administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/15/24.
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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 11/14/2024 09:32 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/14/2024 at 07:45 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: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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4
Based on observation, the licensee did not comply with the section cited above in broken drawer in resident's room which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee and/or administrator to have the drawer fixed and submit picture by 11/28/24.
Type B
Section Cited
CCR
87463(a)(3)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.

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 R2 who had change in condition and admitted back to the facility and LIC625 not updated which poses a potential health, safety and/ or personal rights risks to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Administrator to update R2's LIC625 and submit copy by 11/28/24.
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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 11/14/2024 09:32 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/14/2024 at 07:45 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: 11/14/2024

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
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Based on record review, the licensee did not comply with the section cited above in not conducting the disaster drill every quarter which poses a potential safety risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Administrator to have the drill conducted and submit copy by 11/28/24.
Type B
Section Cited
CCR
87608(a)(3)
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
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2
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4
Based on records review, the licensee did not comply with the section cited above in 5 out of 5 residents' half bed rails not having doctor's orders on file which pose a potential safety and/or personal rights risks to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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2
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Administrator to obtain doctor's order and submit copies by 11/28/24.
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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 11/14/2024 09:32 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/14/2024 at 07:45 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: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87615(a)(1)
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:
(1) Stage 3 and 4 pressure injuries.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above In R2 who has stage 3 pressure injury was admitted back to the facility. which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee to obtain an updated stage of pressure injury from a wound doctor or wound nurse. If stage is still stage 3, licensee stated he'll submit exception request; otherwise submit an updated copy of wound assessment. Document(s) to be submitted by 11/28/24.
Type B
Section Cited
CCR
87458(c)
87458 Medical Assessment
(c) The licensee shall obtain an updated medical assessment when required by the Department.

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 R2's LIC602A indicating R2 needs assistance with all ADLs but R2 can feed self. This poses a potential personal rights risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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2
3
4
Administrator to obtain updated LIC602A and submit copy by 11/28/24
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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 11/14/2024 09:32 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/14/2024 at 08:36 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: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(g)
87211 Reporting Requirements
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in not notifying the Department when a new administrator was hired poses a potential health and/ or personal rights risks to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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2
3
4
Licensee to submit a signed letter along with copies of the new administrator's certificate, LIC501 Personnel Record by 11/28/24.
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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 11/14/2024 09:32 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/14/2024 at 08:46 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: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation and records review, the licensee did not comply with the section cited above in R1 and R5 not having the right medication dosages, not having certain medications, and facility not administering the dosage as precribed which pose an immediate health and/or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Licensee and/or administrator to check with R1 and R5’s physicians for updated doctor’s orders and administer the medications with correct dosage accordingly. If medications are no longer needed, to discontinue administration. Proof to be submitted by 11/15/24.
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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
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: 11/14/2024
NARRATIVE
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Page 3

-at 7:00 pm, resident (R5) doctor's order for prenisolone is 1 mg, 3 tablets daily but medication on hand is 1 mg, 1 tablet daily and facility administers only 1 mg 1 tablet daily. Has PRN order for Senna and Lorazepam and facility does not have these medications.

Deficiencies and plan and proof of corrections were discussed with licensee.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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