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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200982
Report Date: 02/08/2024
Date Signed: 02/08/2024 07:25:27 PM

Document Has Been Signed on 02/08/2024 07:25 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:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lilibeth 'Beth' Toco/House ManagerTIME COMPLETED:
07:30 PM
NARRATIVE
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At 11:00 a.m. on this day, February 8, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with House Manager Lilibeth 'Beth' Toco, and informed the reason for visit. LPA also met with other staff, Benjamin Fonacier.

Facility has Infection Control Plan, copy of which obtained by LPA on this same day.

LPA toured the facility inside out with the house manager. LPA inspected the kitchen, dining area, living room, bedrooms, play room, 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 and sharps were observed locked.

Facility has 2 in 1 carbon monoxide and smoke detector that was tested, and observed functional. Facility conducts fire drills and records showed last conducted January 10, 2024. Fire extinguisher checked, observed fully charge and receipt showed purchased July 20, 2023. Hot water temperature was tested in one of the bathrooms.

LPA reviewed 5 staff and 5 residents records, and interviewed 2 staff and 2 residents. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. P&I were checked and compared with the last recorded balance.


....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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: HEIWA GROWTH HOUSE 1
FACILITY NUMBER: 019200982
VISIT DATE: 02/08/2024
NARRATIVE
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LPA observed the following:
-at 11:20 a.m., construction tools, materials and pails of paint in storage with broken lock in the backyard. . -at 11:28 a.m., hot water temperature at 134 degrees Fahrenheit. This is a repeat violation within 12 month period. The first citation was issued on 2/28/23.
-at 12;20 p.m., S3 was associated on 2023 but no longer associated on 2024. It was not clear how S3 was disassociated.
-at 1:30 p.m., S4 not fingerprint cleared nor associated. S4 has no record of fingerprint clearance and LIC501 Personnel Record on file.
-at 2:45 p.m.-3:05 p.m., LIC601s of resident R1 and R5 not updated.
-at 3:15 pm to 4:00 p.m., R2 has 2 medications with no doctor's order on file. R3 has order for 1 medication but facility does not have the medication nor have discontinued order on file. The quantity of medications for 5 residents listed on the labels with filled date 1/02/24 were more than the quantity received by the facility.

LPA received the following current documents:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety bond coverage

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 and $250.00 civil penalties were assessed for staff not fingerprint cleared and repeat violation respectively, and will continue until corrected.

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

Exit interview conducted. Appeal Rights, LIC421BG and LIC421FC Civil Penalty Assessments, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 02/08/2024 07:25 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/08/2024 at 05:55 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: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 storage with broken lock which poses an immediate health, safety and/or personal rights risk to persons in care
POC Due Date: 02/09/2024
Plan of Correction
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2
3
4
Locked was replaced.
In addition, administrator to in-service the staff and submit copy of tranining topic with attendees signatures by 2/09/24.
Type A
Section Cited
CCR
80088(e)(1)
(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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2
3
4
Based on observation, the licensee did not comply with the section cited above in hot water at 134 degrees Fahrenheit which poses an immediate health and safety risks to persons in care.

This is a repeat violation within 12 month period. A $250.00 civll penalty is assessed
POC Due Date: 02/09/2024
Plan of Correction
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Staff adjusted the temperature to 116 degrees.
In addition, administrator to in-service the staff and ensure temperature is kept within Regulations range. Ptoof to be submitted by 2/09/24.
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: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/08/2024 07:25 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/08/2024 at 06:04 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: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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) Obtain a California clearance or a criminal record exemption as required by the Department

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above for S4 not fingerprint cleared which poses an immediate safety and/or personal rights risk to persons in care.

A $500.00 civil penalty is assessed and will continue for $100.00/day until corrected.
POC Due Date: 02/09/2024
Plan of Correction
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Administrator stated she'll have S4 fingerprinted and will not have S4 work until cleared. Copy of LIC9183 Request for Livescan Service and self-certifcation to be submitted by 2/09/24
Type A
Section Cited
CCR
80075(b)(6)(D)
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication…..
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 above which poses an immediate health and/or personal rights risk to persons in care. R2's two medications have no doctor's order on file. R3 has order for 1 medication but facility does not have the medication nor have discontinued order on file.
POC Due Date: 02/09/2024
Plan of Correction
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Administrator to obtain doctor's order for R2 and discontinued order for R3, and submit copies by 2/09/24.
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: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/08/2024 07:25 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/08/2024 at 06:23 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: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(3).
(k) The following requirements shall apply to medications which are centrally stored: (3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited which poses an immediate health and/or personal right riks to persons in care. The quantity of medications for 5 residents listed on the labels with filled date 1/02/24 were more than the quantity received by the facility.
POC Due Date: 02/09/2024
Plan of Correction
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2
3
4
Administrator to communicate with the pharmacy and ensure that medications have accurate labels. Self-certification to be submitted by 2/09/24,
Section Cited
Deficient Practice Statement
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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: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 02/08/2024 07:25 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/08/2024 at 06:32 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: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in R1 and R5’s LIC601 Identification and Emergency Contact Information not updated which pose a potential personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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Administrator to update the LIC601s and submit copies by 2/22/24.
Type B
Section Cited
CCR
80066(a)
80066 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in S4 not having LIC501 Personnel Record on file which poses potential safety and/or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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2
3
4
Administrator to complete the record and submit proof by 2/22/24/
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: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


LIC809 (FAS) - (06/04)
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