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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200982
Report Date: 02/06/2025
Date Signed: 02/06/2025 04:17:17 PM

Document Has Been Signed on 02/06/2025 04:17 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/
DIRECTOR:		ONO, YUKAFACILITY TYPE:
735
ADDRESS:22857 ALICE STREETTELEPHONE:
(510) 677-6889
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH: Lilibeth 'Beth' Toco/Assistant Administrator-House Manager TIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On this day, February 6, 2025, at 11:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Assistant Administrator/House Manager (ADHM) Lilibeth 'Beth' Toco, and informed the reason for visit. LPA also met with other staff, Benjamin Fonacier. LPA called and let message on Yuka Ono's, licensee-administrator, voicemail.

LPA toured the facility inside out with ADHM. 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. Fire extinguisher checked, observed fully charge and receipt showed purchased October 15, 2024. Facility conducts fire drills and records showed last conducted February 2, 2025. Hot water temperature in one of the bathrooms was tested.

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

LPA observed the following:
-at 11:55 am, hot water temperature at 130.5 degrees Fahrenheit. This is a repeat violation within 12 month period. A citation was issued on February 8, 2024.
-at 2:30 pm, resident (R1) has order for Pravastatin Sodium (20 mg) on LIC602 Physician's Report dated 5/30/24, however, medication in the facility is Rosuvastatin Calcium 5 mg.

....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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: 02/06/2025
NARRATIVE
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LPA received the following current documents on this day:
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 $250.00 civil penalty is assessed for repeat violation, and will continue for $100.00 per day until corrected.

Deficiencies, civil penalty and plan and proof of corrections were discussed with ADHM.

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

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/06/2025 04:17 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/06/2025 at 03:10 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: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, 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 in hot water temperature at 130.5 degrees Fahrenheit which poses an immediate health, safety and/or personal rights risk to persons in care.
This is a repeat violation within 12 month period.
A $250.00 civil penalty is assessed.
POC Due Date: 02/07/2025
Plan of Correction
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Administrator to have the temperature adjusted within Regulations range and submit proof by 2/07/25.
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in Pravastatin Sodium (20 mg) listed on LIC602 dated 5/30/24; however, medication in the facility is Rosuvastatin Calcium 5 mg count which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Corrected.
ADHM obtained copy of current doctor's order while LPA was at the faciltiy.
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: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/06/2025 04:17 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/06/2025 at 03:26 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: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80036(a)
80036 LICENSING FEES
(a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review. the licensee did not comply with the section above for not paying the annual fees for 2022, 2023, 2024 and 2025 ($1816.00) which poses a potential safety and/or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Licensee-administrator to pay the annual fees and submit proof of payment by 2/20/25.
Type B
Section Cited
CCR
8036(b)(1)(F)
80036 Licensing Fees (b)(1) In addition to fees set forth in subdivision (a), the department shall charge the following fees:(F) A late fee that represents an additional 50 percent of the established current annual fee when any licensee fails to pay the current annual licensing fee on or before the due date.

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 in not paying the late fees of $681.00 which poses a potential safety and/or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Licensee-administrator to pay the late fees and submit proof of payment by 2/20/25.
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: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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