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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 01/10/2023
Date Signed: 01/10/2023 06:12:08 PM


Document Has Been Signed on 01/10/2023 06:12 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:SARAH MAY BALINGITFACILITY TYPE:
740
ADDRESS:18905 STANDISH AVENUETELEPHONE:
(510) 276-0939
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:20CENSUS: 16DATE:
01/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Celeste Olivarez/Facility Consultant
and John Olivarez/Licensee		TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to information received from Adeliza Magalonnes. Magallones submitted a copy of facility's Narrative Report for resident (R1) indicating R1 AWOLed on 12/30/22. LPA responded to Magalonnes informing her to use the Departments' LIC624 Unusual Incident Report (UIR) when reporting an incident and requested for copy of LIC602A Physician's Report.

Report indicated that at 4:15 am on 12/30/22, R1 was found not in R1's room. Staff searched the facility and neighborhood and called the police. R1 was found and returned to the facility by the police officer.

On this day, 1/10/23, LPA met with Celeste Olivarez, facility consultant, and staff, Maria Dolores Floriza, and informed the purpose of visit. John Olivarez, licensee, arrived after about an hour,

Review of R1's LIC602A Physician’s Report revealed R1 has dementia, confused/disoriented, has wandering and sundowning behaviors, needs assistance with bathing. dressing and grooming. However, LIC625 Appraisal/Needs and Services Plan not updated to reflect and meet R1's current needs,

LPA conducted interviews, and obtained copy of LIC Personnel Report. LPA conducted inspection with Olivarez and Floriza. LPA checked the front door entrance and sliding exit door at the back of the facility. LPA observed the sliding door's auditory signal not working properly. LPA further observed the sound of the signal is barely heard in staff's room and in other common areas of the facility,


......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 01/10/2023 06:12 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: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/11/2023
Section Cited

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87705 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 evidence
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Licensee to do the following and submit proof by 1/11/23:
1. Replace the auditory signal.
2. In=service the staff.
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-Based on inspection, records review and interview, the licensee did not comply with the section cited above. R1 was able to leave the facility unnoticed which posed immediate health and safety risks to person in care. LPA observed the auditory signal not properly working.
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Type B
01/17/2023
Section Cited

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87705 Care of Persons with Dementia
(c) (5) (A)When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.
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Licensee o do the following and submit proof by 1/17/23:
1, Updated resident's Care Plan.
2. n-service the staff.
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-This requirement is not met as evidence:by:
-Based on, records review, the licensee did not comply with the section above for not updating the Appraisal/Needs and Services to meet R1's current needs which poses potential health and safety risks to person in care,
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 01/10/2023
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections (POCs) by plan of corrections due dates and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of correction were discussed with Celeste Olivarez and 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: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3