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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200982
Report Date: 10/20/2022
Date Signed: 10/20/2022 06:02:14 PM

Document Has Been Signed on 10/20/2022 06:02 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:
10/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Lilibeth 'Beth' Toco/House ManagerTIME COMPLETED:
06:00 PM
NARRATIVE
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While at the facility investigating complaint (Complaint Control # 15-AS-20220427141253), Licensing Program Analyst (LPA) Delmundo learned that residents (R1, R2, and R3) were tested positive of COVID-19. Review of faxed documents revealed a report was not made to Community Care Licensing (CCL) and Local Public Health (LPH). LPA interviewed R1, Lilibeth Toco and Yuka Ono who confirmed the positive cases.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Yuka Ono, administrator, over the phone and with Lilibeth Toco. Licensee indicated she can not come to the facility and authorized Lilibeth Toco to sign and receive this report,

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: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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Document Has Been Signed on 10/20/2022 06:02 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/20/2022 at 05:10 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: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
Section Cited
CCR
87211(a)(2)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such report,.:(2) Ocurrences, such as epidemic outbreaks, ,,,which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile...
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Administrator to read the Regulations and self-certify that reporting requirements will be followed. Proof to be submitted by 10/27/2022.
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....to the licensing agency and to the local health officer .
-This requirement is not met as evidenced by:
-Based on interviews and documents review, the licensee did not comply with the section above for not reporting the COVID-19 cases.
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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: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022


LIC809 (FAS) - (06/04)
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