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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 01/16/2025
Date Signed: 01/16/2025 07:22:43 PM

Document Has Been Signed on 01/16/2025 07:22 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:MORNINGSTAR SENIOR LIVING OF HAYWARDFACILITY NUMBER:
019200922
ADMINISTRATOR/
DIRECTOR:		HENRY, CAYIAFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 170CENSUS: 104DATE:
01/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
06:00 PM
MET WITH:Associate Executive Director (AED) Rosana FriasTIME VISIT/
INSPECTION COMPLETED:
07:25 PM
NARRATIVE
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During investigation of complaint (Control # 15-AS-20240319155109), Licensing Program Analyst (LPA) was provided the following information:
1. Pine Park Health sent order to the facility to check resident's (R1) blood pressure (BP) from 02/07/2024 to 02/14/2024. Information obtained from Pine Park Health staff confirmed there's an order. However, review of R1's record and staff record sent by staff to Pine Park Health showed R1 refused blood pressure check on 02/14/2024 and BP record from 02/16/2024 to 02/19/2024. There's was no record for 02/07/2024 to 02/13/2024. LPA interviewed S1 who was not able to provide information why R1's BP was not checked for the said ordered dates.
2. R1 had overgrown toenails. Pictures obtained by LPA showed R1 had discolored overgrown toenails about 1 to 2 inches long. LPA called the podiatrist clinic who confirmed R1 was seen in 4/2024

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

Deficiency and plan and proof of correction were discussed with AED.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 2
Document Has Been Signed on 01/16/2025 07:22 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/16/2025 at 06:59 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: MORNINGSTAR SENIOR LIVING OF HAYWARD
FACILITY NUMBER: 019200922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2025
Section Cited
CCR
87465(a)(2)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. ...(2) The licensee shall provide assistance in meeting necessary medical and dental needs. .....
-This requirement is not met as evidenced by:
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Resident is no longer at the facility.

AED to in-service the staff and submit proof by 1/30/25.
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-Based on record review and interview, the licensee did not comply with the section in not checking R1 blood pressure as ordered on particular dates which posed a potential health risk to resident in care.
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Type B
01/30/2025
Section Cited
CCR1569.269(a)(6)

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ยง1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers....
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Resident is no longer at the facility.

AED to in-service the staff and submit proof by 1/30/25.
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-This requirement is not met as evidenced by:
-Based on interviews and record review, the licensee did not comply with the section above in R1 having overgrown toenails which posed a potential personal rights risk 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 Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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