<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600756
Report Date: 08/28/2024
Date Signed: 08/30/2024 09:02:42 AM


Document Has Been Signed on 08/30/2024 09:02 AM - 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:ROYAL COLONY VIEW PLACEFACILITY NUMBER:
015600756
ADMINISTRATOR:JULIANA TABURAZAFACILITY TYPE:
740
ADDRESS:2767 COLONY VIEW PLACETELEPHONE:
(510) 889-1288
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:8CENSUS: 5DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Ermi Macaraig/Staff TIME COMPLETED:
07:30 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 this day, August 28, 2023, at 1:40 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Ermi Macaraig, and informed the reason for visit. LPA called and spoke over the phone with Juliana Taburaza, administrator. LPA also met with other staff, Edwin Villarin. Administrator arrived after about 2 hours.

Facility has Infection Control Plan that was submitted on June 30, 2022.

LPA toured the facility inside out with Ermi Macaraig. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has smoke and carbon monoxide detectors that were tested, and observed functional. Hot water temperature in the common bathroom was tested, and measured at 112.8 degrees Fahrenheit. Facility conducts disaster drills every month, and records showed last conducted 8/01/24.

LPA reviewed 3 staff and 5 residents files. Medications inspected and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Record. Resident's P&I checked and compared with last recorded balance.

LPA observed the following:
-at 1:50 pm, peelers in kitchen drawer without lock.
-at 1:56 pm, missing baseboard in the kitchen area.
-at 1:59 pm to 2:01 pm, Tylenol and razors in the resident's room.

........continued on 809C (page 2)
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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 4


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: ROYAL COLONY VIEW PLACE
FACILITY NUMBER: 015600756
VISIT DATE: 08/28/2024
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
26
27
28
29
30
31
32
Page 2

-at 2:01 pm, medications in unlocked staff room.
-at 2:04 pm, hair trimmer in another resident's room.
-at 2:30 pm, shovel in the side yard.
-at 6:15 pm, resident R1's dosage of 1 of the medications was crossed out and changed to 25 mg not by the prescribing doctor. The label on this medication showed 25 mg, 1 tablet everyday; however, the medications inside the bottle were cut into halves. The LIC622 for this medication showed 50 mg and no entry for quantity received by the facility.

Administrator to submit the following updated/current documents by September 11, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with the administrator. Administrator has to leave and have Ermi Macaraig sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/30/2024 09:02 AM - 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: ROYAL COLONY VIEW PLACE
FACILITY NUMBER: 015600756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 for the following which pose an immediate health, safety and/or personal rights risk to persons in care: Tylenol in the resident's room; medications in unlocked staff room; peelers in kitchen drawer without lock; razors and hair cutter in the residents' rooms; shovel in the side yard
POC Due Date: 08/29/2024
Plan of Correction
1
2
3
4
Staff locked the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 8/29/24.
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in one of R1's medications on hand not consistent with the origiinal order and the medication on hand were cut into haves. These pose immediate health and/or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
1
2
3
4
Administrator called the resident's family member while LPA is still at the facility.
In addition, correct order and medication to be obtained. Copy of order and picture of medication to be submitted by 8/29/24.
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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/30/2024 09:02 AM - 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: ROYAL COLONY VIEW PLACE
FACILITY NUMBER: 015600756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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.

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 in missing baseboard in the kitchen area which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
1
2
3
4
Administrator to have the baseboard installed and submit picture by 9/11/24.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in quantity of R1 medication received by the facility not recorded on LIC622 which poses a potential health and/or personal rights risks to person in care.
POC Due Date: 09/11/2024
Plan of Correction
1
2
3
4
Administrator to have the record completed and submit self-certification by 9/11/24.
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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4