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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200750
Report Date: 12/09/2020
Date Signed: 12/09/2020 05:03:32 PM

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:SCOTT VILLAFACILITY NUMBER:
019200750
ADMINISTRATOR:JONABELLE TOLENTINOFACILITY TYPE:
740
ADDRESS:1560 MIDDLE LANETELEPHONE:
(510) 782-7833
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:35CENSUS: 30DATE:
12/09/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Jonabelle Tolentino/AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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During the course of investigation of a complaint (15-AS-20190723130812), Licensing Program Analyst (LPA) Delmundo learned that the facility issued a 30-eviction as a result of resident (R1) hitting another resident. R1's responsible person was not informed of the incident of hitting which LPA confirmed with Jonabelle Tolentino, administrator.

On this day, LPA called and spoke with Ms. Tolentino. LPA informed that due to Shelter in Place Order and directive by management to telework, this case management is done via video conference.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction (POC) along with the LIC9098 Proof of Correction by plan of correction due dates and any repeat violations within 12-month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Ms. Tolentino.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
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: SCOTT VILLA
FACILITY NUMBER: 019200750
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2020
Section Cited

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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have... personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services.......
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This requirement is not met as evidenced by:
-Based on interviews and records review, the licensee did not comply with the Regulation by failing to notify the responsible person of R1’s hospitalization which poses potential personal rights risk to resident 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: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2020
LIC809 (FAS) - (06/04)
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