015601224-1-10-2025-15-AS-ADEO-DCSVX4-20250110154855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601224
Report Date: 01/10/2025
Date Signed: 01/10/2025 03:49:01 PM

Document Has Been Signed on 01/10/2025 03:49 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:	ESCUETA CARE HOME #2		FACILITY NUMBER:	015601224
ADMINISTRATOR/ DIRECTOR:	MILANETTE ESCUETA		FACILITY TYPE:	740
ADDRESS:	1889 WEST STREET		TELEPHONE:	(510) 940-8652
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/10/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:45 AM
MET WITH:	Milanette Escueta/Administrator and Adrian Escueta/Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:45 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	Licensing Program Analyst (LPA) Delmundo conducted a case management as a result of pre-licensing inspection for license application for change in ownership. LPA toured the facility inside out with MIlanette Escueta, administrator (ADM), and Adrian Escueta, assistant administrator (AADM). LPA observed the following: -at 11:55 a.m., expired salad dressing and mustard and rotten head lettuce. -at 12:05 p.m., greasy cabinets by cooking range. -at 12:10 p.m., nail polish remover, ant and roach killer and chest rub in unlocked staff room. -at 12:20 p.m., moldy shower areas in common and ensuite bathrooms. -at 12:25 p.m., gallons of paint, oxygen tank, construction materials such as grout, grout cleaner. stain and rust remover in unlocked storage. -at 12:26 p.m., area rug and weight machine in the side yard. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $250.00 civil penalty each for section 87303(a) and 87309(a) for repeat violations within 12 month period. Failure to submit proof of corrections (POCs) by plan of correction due dates may result in additional civil penalties. Deficiencies and plan and proof of corrections were discussed with ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Bennett Fong	TELEPHONE: (510) 622-2621
Alicia Delmundo	TELEPHONE: (510) 286-4201
	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

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 01/10/2025 03:49 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: ESCUETA CARE HOME #2	FACILITY NUMBER: 015601224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87555 General Food Service Requirements: (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents.......... -This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/11/2025
	Plan of Correction
1 2 3 4	Staff threw away the items. In addition, administrator to in-service the staff and submit proof by 1/11/25.

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.

Bennett Fong	TELEPHONE: (510) 622-2621
Alicia Delmundo	TELEPHONE: (510) 286-4201
	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/10/2025 03:49 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: ESCUETA CARE HOME #2	FACILITY NUMBER: 015601224
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	Administrator stated she'll do the following: 1. Have the yard cleaned. 2. Have kitchen cabinets cleaned and install metal to serve as wood protector. Pictures to be submitted by 1/24/25. A $250.00 civil penalty is assessed,

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.

Bennett Fong	TELEPHONE: (510) 622-2621
Alicia Delmundo	TELEPHONE: (510) 286-4201
	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

LIC809 (FAS) - (06/04)

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