015600756-8-10-2023-15-AS-ADEO-CUL3S8-20230810182955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600756
Report Date: 08/10/2023
Date Signed: 08/10/2023 06:30:03 PM

Document Has Been Signed on 08/10/2023 06:30 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:	ROYAL COLONY VIEW PLACE		FACILITY NUMBER:	015600756
ADMINISTRATOR:	JULIANA TABURAZA		FACILITY TYPE:	740
ADDRESS:	2767 COLONY VIEW PLACE		TELEPHONE:	(510) 889-1288
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	8	CENSUS: 5	DATE:	08/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Letecia Iroy/Staff		TIME COMPLETED:	06:30 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 10, 2023, at 11:40 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Letecia Iroy, and informed the reason for visit. LPA called and spoke over the phone with Juliana Taburaza, administrator. LPA asked, and administrator stated she can not come to the facility, and authorized Letecia Iroy to be with LPA during inspection and sign and receive this report. Facility has Infection Control Plan that was submitted on June 30, 2022. LPA toured the facility inside out. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, 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 one of the bathrooms was tested, and measured at 113.8 degrees Fahrenheit. Facility conducts disaster drills quarterly, and records showed last conducted 7/02/23. LPA reviewed 4 staff and 5 residents files, and interviewed 1 staff and 2 residents. Medications checked, and compared with records and doctor's orders. LPA verified, and according to the administrator, facility handles only 2 residents' P&I. ...continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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: ROYAL COLONY VIEW PLACE	FACILITY NUMBER: 015600756
	VISIT DATE: 08/10/2023

NARRATIVE

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LPA observed the following:
-at 12:18 pm, wood plank of the deck in the backyard with hole and some planks have signs of wearing out.
-at 12:40 pm, LPA verified and S2 stated she administers medications; however, records showed no 8 hours required annual training for year 2022. S2 only has 4 hours dementia & no postural support/restricted health/hospice care training on file for year 2022. S3 who administers medications does not have 8 hours required annual training for year 2022
-at 1:30 and 1:45 pm, S3 and S4 has only 4 hours dementia & no postural support/restricted health/hospice care training on file for year 2022.
-at 2:40 pm, residents' (R1, R2 & R3) LIC625 Appraisal/Needs and Services Plan on file are over a year old
-at 4:00 pm, R3 has 2 medications but no doctor's order on file. Doctor's order on file for other 1 medication was 25 mg (1 tab at bedtime) but the medication on facility's hand is 50 mg (1 tab at bedtime).
-P&1 cash and records of 2 residents (R3 and R4) are not in the facility.

Administrator to submit the following updated/current documents by August 24, 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 penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator over the phone in the presence of Letecia Iroy.

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/10/2023 06:30 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: ROYAL COLONY VIEW PLACE	FACILITY NUMBER: 015600756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 4 staff only have 4 hours dementia training and no 4 hours required postural supports, restricted health conditions, and hospice care training on file which pose a potential health, safety and/or personal rights risks to persons in care.
	POC Due Date: 08/24/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff complete the required training, and submit by 8/24/23 a self-certification they are completed.

Type B

Section Cited

HSC

1569.69(b)

§1569.69 Employees assisting residents with self-administration of medication; training requirements (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 4 staff not having on fille the required annual medication training for year 2022 which poses a potential health and/or personal rights risks to persons in care.
	POC Due Date: 08/24/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff trained, and submit proof by 8/24/23.

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) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/10/2023 06:30 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: ROYAL COLONY VIEW PLACE	FACILITY NUMBER: 015600756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(e)

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for R3 not having doctor's order for 2 medications and 1 medication on facilty's hand with dosage different from what is on the order on file which pose an immediate health and/dor personal rights risk to person in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Administratot the obtain doctor's order, and submit copies by 8/11/23.

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) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/10/2023 06:30 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: ROYAL COLONY VIEW PLACE	FACILITY NUMBER: 015600756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 3 out of 5 residents' LIC625 Appraisal/Needs and Services Plan on file over a year old which poses a potential health and/or personal rights risks to persons in care.
	POC Due Date: 08/24/2023
	Plan of Correction
1 2 3 4	Administrator to complete the appraisal, and submit eelf-certification by 8/24/23.

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 records review and interview, the licensee did not comply with the section above for not having the P&I records of 2 residents available for review which poses a potential personal rights risk to persons in care.
	POC Due Date: 08/24/2023
	Plan of Correction
1 2 3 4	Administrator to read the Regulation, and self-certify that in the future files will be made readilty available for review. Proof to be submitted by 8/24/23.

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) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/10/2023 06:30 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: ROYAL COLONY VIEW PLACE	FACILITY NUMBER: 015600756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a)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 for the deck with hole and wood planks with signs of wearing out which poses a safety risk to persons in care
	POC Due Date: 08/24/2023
	Plan of Correction
1 2 3 4	Administrator stated she'll have the deck repaired. Picture to be submitted by 8/24/23.

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) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

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