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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200982
Report Date: 02/28/2023
Date Signed: 02/28/2023 04:37:59 PM

Document Has Been Signed on 02/28/2023 04:37 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:HEIWA GROWTH HOUSE 1FACILITY NUMBER:
019200982
ADMINISTRATOR:ONO, YUKAFACILITY TYPE:
735
ADDRESS:22857 ALICE STREETTELEPHONE:
(510) 677-6889
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Staff Benjamin Ponacier
and Myrla Moralina		TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff,Benjamin Ponacier and Myrla Moralina, and informed the purpose of visit. LPA called and spoke with Yuka Ono, administrator, over the phone. Lilibeth Toco, hluse manager, arrived after about 45 minutes.

Facility has an approved LIC808 Mitigation Plan. Facility has not submitted the LIC9282 Infection Control Plan.

LPA toured the facility inside out with Benjamin Ponacier. LPA inspected the living room, dining area, activity room, kitchen, hallways, residents bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. Central storage for medications and cabinet and storage for laundry and cleaning supplies were observed locked.

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked. Facility has antigen test kits readily available. COVID-19 signages were observed in some areas of the facility. Bathroom lavatories were observed with liquid soap. Trash cans were observed with no touch lids.

Fire extinguisher checked, observed fully charge with receipt showed purchased July 14. 2022. Hot water temperature in one of the common bathrooms was tested.

.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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 5
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: HEIWA GROWTH HOUSE 1
FACILITY NUMBER: 019200982
VISIT DATE: 02/28/2023
NARRATIVE
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LPA observed the following:
1. Hot water temperature at 131 degrees Fahrenheit.
2. Staff not wearing mask.
3. Staff (S1) not associated to the facility.
4. Supplies of N95 resoirator (60 pcs) and disposable gowns (40 pieces) not sufficient for 30 days for 7 staff.

Administrator to submit the following by March 14, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety bond coverage
5. Current N95 fit testing records/certificates
6. LIC9282 Infection Control Plan

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 violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Yuka Ono over the phone and with Lilibeth Toco.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/28/2023 04:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2023 at 04:19 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: HEIWA GROWTH HOUSE 1
FACILITY NUMBER: 019200982

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088 Furniture, Fixtures, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 for hot water at 131 degrees Fahrenheit which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 03/01/2023
Plan of Correction
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Staff to adjust the temperature.
In addition, administrator to in-service the staff and submit proof by 3/01/23.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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: 02/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/28/2023 04:38 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2023 at 04:23 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: HEIWA GROWTH HOUSE 1
FACILITY NUMBER: 019200982

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(2)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 80019(f)

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 for 1 staff not asoiated which poses/posed a potential safety risk to persons in care.
POC Due Date: 03/14/2023
Plan of Correction
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Administrator to have the staff associated, and submit proof by 3/14/23.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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: 02/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023


LIC809 (FAS) - (06/04)
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