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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440152
Report Date: 01/09/2025
Date Signed: 01/09/2025 04:52:27 PM

Document Has Been Signed on 01/09/2025 04:52 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:GALICIA'S TULIP CARE HOMEFACILITY NUMBER:
011440152
ADMINISTRATOR/
DIRECTOR:		GALICIA, CONSUELOFACILITY TYPE:
740
ADDRESS:1771 TULIP AVE.TELEPHONE:
(510) 782-6355
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 0TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
01/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Rolando Galicia/Licensee TIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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On this day, 1/09/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit as a result of investigation of a complaint (Control # 15-AS-20221115154918). LPA called and spoke over the phone with Consuelo ‘Connie’ Galicia, licensee/administrator who stated she can not come to the facility and will have Rolando Galicia, licensee, meet LPA.


During investigation, LPA obtained information from resident’s (R2) family members that R2 fell on November 2022 which resulted to R2 sustaining bruises. R2’s family members were informed of the un-witnessed fall but not the bruises. Facility staff did not send R2 out to the hospital. When R2’s family member came to the facility the following day, the family member observed the bruises and it’s the family member who brought R2 to the hospital. After Visit Summary dated November 5, 2022 obtained by LPA from the family member showed the following – reason for visit: head injury; diagnosis: hematoma of the scalp.

Review of records obtained showed only 1 Unusual Incident Report (UIR) dated 11/10/22. Licensee stated there’s only 1 UIR during R2 entire stay in the facility.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil penalty is assessed for section 87465(a)(2).

Deficiencies and civil penalty were with the licensee.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment and copy of this report provided.
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201
DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/09/2025 04:52 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: GALICIA'S TULIP CARE HOME
FACILITY NUMBER: 011440152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87465 Incidental Medical and Dental Care (a) .....(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical .......
-This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 01/10/2025
Plan of Correction
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Residents are no longer at the facility and licensee surrendered the license.

A $500.00 civil penalty is assessed.
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.
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201

DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025

LIC809 (FAS) - (06/04)
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