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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200670
Report Date: 06/27/2022
Date Signed: 06/27/2022 02:27:20 PM


Document Has Been Signed on 06/27/2022 02:27 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:ACAPULCO SENIOR CARE HOMEFACILITY NUMBER:
019200670
ADMINISTRATOR:KA, NINFACILITY TYPE:
740
ADDRESS:14160 ACAPULCO ROADTELEPHONE:
(510) 924-7457
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:6CENSUS: 3DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Elmore Shipley, Care StaffTIME COMPLETED:
02:35 PM
NARRATIVE
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On 6/27/22 at 1:00 p.m., Licensing Program Analyst (LPA) G. Clark arrived unannounced to conduct Infection Control Inspection. LPA spoke with Joyce Rodrigues who agreed to have Elmore Shipley, Care Staff sign the visit forms. LPA explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to: front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff prompted to be wear proper PPE. Facility has a 30-day supply of PPE maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

At 1:05 p.m. LPA observed a car being repaired in the driveway of the facility. There were several extension cords and power tools easily accessible to persons in care. There were 2 non-staff present in the driveway working on the car. Several parts of the front of the car had been removed and were outside the facility's front door. This poses an immediate health, safety or personal rights risk to persons in care.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations failure to correct deficiencies by POC date may result in additional Civil Penalties.

Deficiencies cited during visit. Exit interview conducted, appeal rights and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
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 06/27/2022 02:27 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: ACAPULCO SENIOR CARE HOME
FACILITY NUMBER: 019200670

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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Based on observation, the licensee did not comply with the section cited above as evidenced by: LPA observed a car being repaired in the driveway of the facility. There were several extension cords and power tools easily accessible to persons in care. There were 2 non-staff present in the driveway working on the car. Several parts of the front of the car had been removed and were outside the front door of the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2022
Plan of Correction
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Administrator agreed to tell the individuals working on the car to remove it immediately. LPA observed that the car, power tools and extension cords were all removed during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
LIC809 (FAS) - (06/04)
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