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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600176
Report Date: 06/28/2024
Date Signed: 06/28/2024 08:07:38 PM


Document Has Been Signed on 06/28/2024 08:07 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:HAILEY'S CARE HOMEFACILITY NUMBER:
075600176
ADMINISTRATOR:RIFORMO, MARIAFACILITY TYPE:
740
ADDRESS:3831 LA COLINA ROADTELEPHONE:
(510) 222-0945
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 2DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria Riformo, Administrator TIME COMPLETED:
08:45 PM
NARRATIVE
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On 06/28/2024 around 03:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived announced to conduct a required annual inspection. LPA contacted Maria Riformo (ADM) and explained the purpose of the visit; the facility previously had zero (0) clients. Licensee currently holds a standard certificate (#6006016740) exp. 04/06/2025. The facility’s fire clearance was approved for six (6), no more than four (4) non-ambulatory residents and one (1) bedridden; census is two (2).

LPA and ADM toured the facility including, but not limited to common areas, bathroom, bedrooms, kitchen, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. All hand washing stations were equipped with soap, paper towels and covered garbage cans. There was a surplus of PPE centrally located inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 114.7 degrees Fahrenheit (F) and the facility's temperature was comfortable at 74 degrees Fahrenheit (F). Fire extinguisher was observed full. Smoke detectors were observed operational and first aid kit complete.

Continued on LIC809C...
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
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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Document Has Been Signed on 06/28/2024 08:07 PM - It Cannot Be Edited

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: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in one (1) out of three (3) residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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Licensee to have R1's responsible party sign an admission agreement, update R1's resident file with the required CCLD forms, and read the regulation. Licensee to provide CCLD with copies of R1's admission agreement, physician's report, and ID/Emergency contact information; self-certify that the remaining forms are current and complete in R1's file.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/28/2024 08:07 PM - It Cannot Be Edited

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: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 by not having a carbon monoxide detector in operating condition which poses a potential health and safety risk to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
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Administrator will purchase new carbon monoxide detectors an install them, purchase a fire extinguisher, and provide CCLD a copy of the receipt and photos of installation to CCLD by the POC date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in two (2) out of three (3) Caregivers not possessing evidence of first aid and/or CPR certification in the staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
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Licensee to provide proof of first aid and CPR training for Caregivers to CCLD by the POC date to ensure that one (1) staff is trained on duty and on the premises at all times.
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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/28/2024 08:07 PM - It Cannot Be Edited

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: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in two (2) out of three (3) staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee to provide proof of training to CCLD by the POC date that meets the requirements of an additional 20 hours of training annually per the above regulation.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in one (1) out of two (2) resident files which poses a potential health, safety or personal rights risk to a resident (R2) in care.
POC Due Date: 07/05/2024
Plan of Correction
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Licensee to provide proof of a doctor's order to CCLD by the POC date for a bed rail that extends from the head half the length of the bed for R2.
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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9


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: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176
VISIT DATE: 06/28/2024
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...continued from LIC809.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.


LPA observed the following deficiencies during course of inspection:
At 3:45 PM – LPA observed a bedrail and absence of a doctor’s order in resident’s (R2) file.
At 4:00 PM – LPA observed absence of carbon monoxide detectors and expired fire extinguisher.
At 4:35 PM – LPA observed absence of staff’s training records, first aid and CPR certification.
At 5:00 PM – LPA observed resident (R1) at the facility. Licensee stated that R2 visits and stays at the facility sometimes. R1 does not have an admission agreement.

The following forms are to be updated and submitted to CCLD on or before 07/12/24:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610D Emergency Disaster Plan
-Certificate of Liability Insurance

Exit interview conducted, appeal rights and a copy of this report provided to Licensee, Maria Riformo.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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