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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201017
Report Date: 11/10/2021
Date Signed: 11/10/2021 12:00:57 PM

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:AQUINO'S CARE HOMEFACILITY NUMBER:
079201017
ADMINISTRATOR:AQUINO, MARICELFACILITY TYPE:
740
ADDRESS:2481 RAMONA STREETTELEPHONE:
(559) 303-7020
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:6CENSUS: 5DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Loida Paningbatan, caregiver TIME COMPLETED:
12:15 PM
NARRATIVE
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On 11/10/2021 at 8:30 am, Licensing Program Analyst and Licensing Program Manager (LPA & LPM) C. Fowler and J. Fong arrived unannounced to conduct an required annual/Infection Control Inspection. LPA and LPM met with caregiver Loida Paningbatan, and explained the purpose of the visit.

Upon entry, LPA and LPM temperatures were checked by staff. LPA and LPM toured facility including but not limited to bedrooms, bathrooms, kitchen, garage, common areas, and outdoor areas. LPA and LPM observed hand washing posters posted at bathrooms and sinks.

During record review, LPA and LPM observed visitors log and temperature logs for residents and staff. LPA and LPM observed facility has a copy of Mitigation Plan on file. LPA and LPM observed PPE and paper supplies are sufficient.

Deficiency: LPA C. Fowler and LPM J. Fong observed that one resident had a half bed rail (which was down) without a MD order.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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: AQUINO'S CARE HOME
FACILITY NUMBER: 079201017
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(3)
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record

This requirement is not met as evidenced by:LPA C Fowller observed that one resident had half bed rails (which were down) without an MD order.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses a potential health and safety risk to persons in care.
POC Due Date: 11/24/2021
Plan of Correction
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Facility immediatly removed bed rails in LPA and LPM presance. Defency cleared.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021
LIC809 (FAS) - (06/04)
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