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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200694
Report Date: 12/18/2025
Date Signed: 12/18/2025 04:44:35 PM

Document Has Been Signed on 12/18/2025 04:44 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:H & M HOMES STANDISHFACILITY NUMBER:
019200694
ADMINISTRATOR/
DIRECTOR:		OLIVE LOPEZFACILITY TYPE:
740
ADDRESS:18543 STANDISH AVENUETELEPHONE:
(510) 276-2240
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 5DATE:
12/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH: Olive 'Lyn' Neri/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On this day, December 18, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Nancy Amistad, and informed the reason for visit. LPA called and spoke over the phone with Olive 'Lyn' Neri, administrator (ADM) who authorized Nancy Amistad to with LPA in touring the facility. LPA also met with other staff, Myriel Danilo Espiritu. ADM arrived at around 11:55 am with other John Louie Neri.

LPA toured the facility inside out. LPA inspected the kitchen, dining area, living room, bedrooms, common and ensuite bathrooms, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Smoke and carbon monoxide detectors were tested, and observed in operating condition during visit. Facility conducts disaster drills every quarter and records showed last conducted December 15, 2025. Fire extinguisher checked, observed fully charge with tag showed serviced July 26, 2025. Hot water temperature in the ensuite bathroom was tested and measured at 111. 6 degrees Fahrenheit.

LPA reviewed 5 staff and 5 residents records. Medications inspected and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders. Residents' P&I checked and compared with last recorded balance.

......continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
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: H & M HOMES STANDISH
FACILITY NUMBER: 019200694
VISIT DATE: 12/18/2025
NARRATIVE
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On this same day, LPA received the updated/current copies of the following documents:
1. LIC308 Designation of Facility Responsibility.
2. LIC500 Personnel Report
3. LIC610E Emegency Disaster Plan (9 pages)
4. $3M liability insurance certificate
5. Proof of Surety Bond coverage

The following deficiencies were observed and cited from Title 22 California Code of Regulations and listed on 809Ds.

-at 10:22 am, CA-Rezz incontinent wash in the kitchen cabinet without lock.
-at 10:23 and 10:25 am, peeler and can opener in other kitchen cabinets without lock.
-at 10:26 am, heavily scratched kitchen island, dusty and soiled upright kitchen cabinets, and greasy and rusty cooking range.
-at 10:28 am, unlocked screw driver in the laundry area.
-at 10:32 am, CA-Rezz incontinent wash and wound cleanser in residents' room.
-at 10:43 am, CA-Rezz incontinent wash and wound cleanser in another resident's room.
-a resident has Oxygen and there's no signs posted.
-at 10:47 am, inside of the refrigerator in the storage dirty.
-at 10:50 am, rotten dining bench in the backyard.
-at 2:00 pm, staff (S5) does not have the required 4 hours postural support, restricted health condition and hospice care training.

Deficiencies and plan and proof of corrections were discussed with the ADM. Failure to submit proof of corrections by plan and correction of due dates and any repeat violation may result in civil penalty.

Exit interview conducted. Appeal Rights, 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: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2025 04:44 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/18/2025 at 03:43 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: H & M HOMES STANDISH
FACILITY NUMBER: 019200694

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025

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 in the following which pose an immediate health, safety and/or personal rights risks to persons in care: unlocked CA-Rezz incontinent wash and wound cleanser; peeler and can opener in kitchen cabinets without locks; unlocked screw driver in the laundry area
POC Due Date: 12/19/2025
Plan of Correction
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Staff locked the items.
In addition, administrator stated she'll in-service the staff. Copy of training topic with attendees signature to be submitted by 12/19/25.
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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2025 04:44 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/18/2025 at 03:43 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: H & M HOMES STANDISH
FACILITY NUMBER: 019200694

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025

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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Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: heavily scratched kitchen island; dusty and soiled upright kitchen cabinets; greasy and rusty cooking range; refrigerator dirty; rotten dining bench in the backyard.
POC Due Date: 01/02/2026
Plan of Correction
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Saff cleaned the cooking range while LPA was at the facilty:
In addition, administrator stated she'll have the refrigerator, kitchen island and cabinets cleaned, discard and replace the dining bench. Pictures to be submitted by 1/02/26.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 S5 not having the required 4 hours postural support, restricted health condition and hospice care training which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
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Administrator to have the staff complete the training and submit proof by 1/02/26.
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: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2025 04:44 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/18/2025 at 03:43 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: H & M HOMES STANDISH
FACILITY NUMBER: 019200694

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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 not having signs posted for Oxygen which pose a potential safety and/or personal rights risks to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
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Corrected.
Administrator posted signs.
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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
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