019200750-5-5-2023-15-AS-ADEO-CRK4H5-20230505190634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200750
Report Date: 05/05/2023
Date Signed: 05/05/2023 07:07:16 PM

Document Has Been Signed on 05/05/2023 07:07 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:	SCOTT VILLA		FACILITY NUMBER:	019200750
ADMINISTRATOR:	JONABELLE TOLENTINO		FACILITY TYPE:	740
ADDRESS:	1560 MIDDLE LANE		TELEPHONE:	(510) 782-7833
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	35	CENSUS: 35	DATE:	05/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jonabelle Tolentino/Administrator		TIME COMPLETED:	06:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day, May 5, 2023, at 11:00 a.m, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Jimmy Tolentino. LPA met with Jonabelle Tolentino, administrator, and other staff, Wendy Wong and Olive Manalastas. Facility has an approved LIC808 Mitigation Plan, and on facility file, an LIC9282 Infection Control Plan; LPA inspected the facility inside and out including but not limited to common areas, bedrooms, bathrooms, shower room, living/activity room, kitchen, dining area, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced February 23, 2023. Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the ensuite toiet was tested, and measured at 105.4 degrees Fahrenheit. Facility conducts disaster drills every 3 months, and records showed last conducted March 1, 2023. LPA reviewed 5 residents and 5 staff files, and interviewed 3 staff and 3 residents. Medications were checked and compared with records. Facility does not handle residents' cash resources. LPA observed the following: -at 11:13 am, a protruding pipe about 8 1/2 inches high from the ground in the front yard. -at 11:40 am, staff's medication in unlocked cabinet in unlocked kitchen. -at 12:00 noon, latch in sliding door in resident's room leading to the front yard, and administrator stated the resident has behavior of opening the door. The door has no auditory alarm. .......continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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
	VISIT DATE: 05/05/2023

NARRATIVE

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-at 12:34 pm and 12:40 pm, shaving cream, and Lysol & Glade spray in the ensuite toilets in
residents rooms.
--at 1:00 pm, all sliding doors in resident rooms leading to the yard have no auditory signal/alarm.

LPA received the following updated documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. LIC9282 Infection Control Plan
4. Proof of $3M liability insurance coverage

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/05/2023 07:07 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: SCOTT VILLA	FACILITY NUMBER: 019200750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having the Lysol and Glade spray and shaving cream unlocked and readily accessible to residents which pose an immediate health and safety risks to persons in care.
	POC Due Date: 05/06/2023
	Plan of Correction
1 2 3 4	Administrator locked the items. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/06/23.

Type A

Section Cited

CCR

87309(b)

Storage Space

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation. the licensee did not comply with the section cited above for staff's medication in unlocked cabinet in unlocked kitchen which poses an immediate health and safety risks to persons in care.
	POC Due Date: 05/06/2023
	Plan of Correction
1 2 3 4	Administrator took the item. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/06/23.

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: 05/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/05/2023 07:07 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: SCOTT VILLA	FACILITY NUMBER: 019200750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(j)

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 evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above for all sliding doors without alarm and instead has a latch in one of them which pose a potential personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Corrected. Auditory devices installed and latch emoved while LPA was at the facility.

Type B

Section Cited

CCR

87703(a)

87303 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed a protruding pipe about 8 1/2 inches high from the ground in the front yard which a potential safety risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Administrator to have the pipe fixed and submit picture by 5/12/23.

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: 05/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

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