015600467-6-25-2021-15-AS-LIBO-C4BQVQ-20210625123044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600467
Report Date: 06/25/2021
Date Signed: 06/25/2021 12:30:52 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:	A-R RESIDENTIAL CARE FOR ELDERLY		FACILITY NUMBER:	015600467
ADMINISTRATOR:	BAUTISTA, ROMULO		FACILITY TYPE:	740
ADDRESS:	4733 DARLENE COURT		TELEPHONE:	(510) 475-9058
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 5	DATE:	06/25/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Alejandria Bautista		TIME COMPLETED:	12:45 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 6/25/2021, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with staff Michelle Valdez and informed the purpose of visit, while conducting facility tour, staff Alejandria Bautista and Administrator Romulo Bautista joined LPA the facility tour. Facility has census of 5. LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. Facility has enough supplies of paper , PPE and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. Facility has enough 2-day perishable food and one-week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A thermometer and hand sanitizer were observed at screening station. Social distancing and hand washing posters were observed. Facility has a mitigation plan. ......Continued to LIC809C....

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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: A-R RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 015600467
	VISIT DATE: 06/25/2021

NARRATIVE

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LPA observed the following:
Routine symptom screening (+/- temperature and symptom check) has NOT been initiated at entry for all staff, residents, and visitors – facility was only checking for temperature and not all covid19 symptoms per interview and document review.

Facility does NOT document daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents – facility staff was only checking for temperature and not all covid19 symptoms per interview and document review.

Signs are NOT posted throughout facility to promote , cough/sneeze etiquette, and other necessary covid19 posters – Facility has incomplete covid19 poster, LPA shared covid19 poster to Administrator to post at the facility.

S1 was observed not wearing mask upon entry of LPA.

Licensee/Administrator has NOT provided all staff fit testing for N95 respirators- Facility Administrator will schedule FIT testing for all staff, report needed to be sent to LPA, on or before 7/16/2021.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Administrator Romulo Bautista.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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: A-R RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 015600467
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. 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 S1 was observed not wearing mask upon entry of LPA which poses/posed a potential health, safety risk to persons in care.
	POC Due Date: 07/02/2021
	Plan of Correction
1 2 3 4	Administrator will conduct training for all staffs regarding infection control, including but not limited to mask wearing or use of proper PPE. Traning documentation will need to be sent to LPA L.Ibo on or before 7/2/202.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

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