079201017-9-5-2024-15-AS-CFOR-D8TVJE-20240905162838

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201017
Report Date: 09/05/2024
Date Signed: 09/05/2024 04:28:56 PM

Document Has Been Signed on 09/05/2024 04:28 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:	AQUINO'S CARE HOME		FACILITY NUMBER:	079201017
ADMINISTRATOR:	AQUINO, MARICEL		FACILITY TYPE:	740
ADDRESS:	2481 RAMONA STREET		TELEPHONE:	(559) 303-7020
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY:	6	CENSUS: 5	DATE:	09/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Jocelyn Bacani Caregiver		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/05/2024 at 12:10 PM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge, conducted an unannounced annual 1-year required inspection. LPAs met with Jocelyn Bacani, Caregiver. Administrator Tranquilino Aquino arrived at 1:00 PM and LPAs explained the purpose of the visit. The facility’s fire clearance was approved for six (6) non-ambulatory. Administrator Maricel Aquino arrived at 3:45 PM. LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of six (6) bedrooms and three (3) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared clients’ bathroom was measured at 139.1 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke detectors/carbon monoxide were in operating condition during visit. The emergency disaster plan was last updated 06/01/2024. Fire extinguisher was last serviced 08/15/2023. Fire drill last conducted 06/01/2024. First aid kit was observed to be complete.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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 09/05/2024 04:28 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: AQUINO'S CARE HOME	FACILITY NUMBER: 079201017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 by having hot water temperature in the shared residence bathroom 139.1 degrees Fahrenheit. which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Administrator agree to adjust hot water temperature and submit a video of the hot water being adjusted. to be submitted to the department by the POC date.

Type A

Section Cited

CCR

87203

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 by having an expired fire extinguishers which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have all fire extinguishers served and submit a copy of the service tag to the department by the POC date.

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	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/05/2024 04:28 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: AQUINO'S CARE HOME	FACILITY NUMBER: 079201017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. 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 by not having shower floors stained, which poses a potential health and risk to persons in care.
	POC Due Date: 10/05/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have shower floors in bathroom 1 and 2 repaired and submit photos to the department by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

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
	VISIT DATE: 09/05/2024

NARRATIVE

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Continue from LIC 809

LPA reviewed five (5) residents files which were all complete. LPA reviewed four (4) staff files which were all complete.

LPA observed the following deficiencies:
· At 12:47 PM, LPAs observed the shower floor in bathrooms one and two stained..
· At 12:48 PM, LPAs observed water temperature in shared bathroom 139.1 degrees Fahrenheit..
· At 12:50 PM, LPAs observed fire extinguishers were expired.

LPAs requested the following documents to be submitted to CCLD by 09/12/2024

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (9 pages)
Liability Insurance
Last Disaster Drill Conducted Document

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

Exit interview conducted and a copy of this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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