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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601224
Report Date: 02/03/2024
Date Signed: 02/03/2024 05:13:24 PM


Document Has Been Signed on 02/03/2024 05:13 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 #2FACILITY NUMBER:
015601224
ADMINISTRATOR:MILANETTE ESCUETAFACILITY TYPE:
740
ADDRESS:1889 WEST STREETTELEPHONE:
(510) 940-8652
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 5DATE:
02/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Dianne Necesito/Staff and
Adrian Escueta/Co-Administrator 		TIME COMPLETED:
05:15 PM
NARRATIVE
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On this day, February 3, 2024, at 10:45 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Dianne Necesito, staff, and informed the reason for visit. LPA called and spoke with Adrian Escueta, co-administrator, who cannot come to the facility at the moment, and authorized Dianne Necesito to be with LPA in touring the facility. Co-administrator arrived 1:15 p.m. LPA also met with other staff, Sunday Contreras,

The facility has LIC9282 Infection Control Plan.

LPA toured the facility inside out. 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 one of the bathrooms was tested, and measured at 112.6 degrees Fahrenheit. Fire extinguisher was observed fully charge with tag showed serviced 3/14/23.

LPA reviewed 5 residents and 5 staff files, and interviewed 2 staff and 2 residents. Medications were checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Residents' P&Is were checked and compared with records.

.....continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2024
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: ESCUETA CARE HOME #2
FACILITY NUMBER: 015601224
VISIT DATE: 02/03/2024
NARRATIVE
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LPA observed the following:
-at 11:00 am, pizza cutter in unlocked kitchen drawer
-at 11:09 a.m., CA-Rezz incontinent wash and ointments in residents' room and ensuite bathroom respectively.
-at 11:30 a.m.,dilapidated tiles in the shower area in the common bathroom.
-at 12:10 p.m., staff (S3, S4 and S5) incomplete training for 2023
-at 2:00 p.m. disaster drill last conducted 3/2023
-at 2:20 p.m. to 2:40 p.m., residents (R1, R2 & R5) LIC602A Physician's Report and LIC625 Appraisal/Needs and Services Plan were over a year old. R4's LIC625 also over a year old.
at 3:00 p.m, residents' (R1 and R2) P&I on facility's hand are more than the last recorded balance.

LPA received copies of the following documents:
1. LIC610E Emergency Disaster Plan.
2. LIC9282 Infection Control Plan

Co-administrator to submit copies of the following updated/current documents by February 17, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. $3M Liability Insurance certificate
4. Proof of Surety Bond coverage

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 co- administrator.

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: 02/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/03/2024 05:13 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: 02/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for unlocked pizza cutter, resident's ointments and incontinent wash ] which pose an immediate health and safety risks to persons in care.
POC Due Date: 02/04/2024
Plan of Correction
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Staff locked the items.
In addition, co-administratorr in-service the staff abd submit proof by 2/04/24.
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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2024 05:13 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: 02/03/2024

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
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Based on observation, the licensee did not comply with the section cited above in dilapidated tiles in the shower area in the common bathroom poses a potential safety and/orersonal rights risk to persons in care.
POC Due Date: 02/17/2024
Plan of Correction
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Licensee to have the tiles fixed and sumbit pictures by 2/17/24.
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
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff with incomplete number of hours of training which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 02/17/2024
Plan of Correction
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Co-administrator to have the staff complete the training. Self-certification to be submitted by 2/17/24.
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: 02/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 02/03/2024 05:13 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: 02/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above for not conducting drills as required which poses a potential safety risk to persons in care.
POC Due Date: 02/17/2024
Plan of Correction
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Licensee to have drills conducted and submit copy by 2/17/24.
In addition, licensee to ensure drills are conducted as required.
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
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Based on records review, the licensee did not comply with the section cited above in R1, R2, R4 and R5s LIC625 over a year old which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 02/17/2024
Plan of Correction
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Co-administrator to have the LIC625s updated and submit self-certification they are completed by 2/17/24.
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: 02/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 02/03/2024 05:13 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: 02/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)
87458 Medical Assessment
(c) The licensee shall obtain an updated medical assessment when required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in R1, R2 and R5's lIC602As over a year old which pose a potential health risk to persons in care.
POC Due Date: 02/17/2024
Plan of Correction
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Co-administrator stated he'll schedule medical appoitnments and have the LIC602s updated. Slef-certification to be submitted by 2/17/24.
Type B
Section Cited
CCR
87217(g)
87217 Safeguards for Resident Cash, Personal Property, and Valuables
(g) Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 residents with inaccurate records of P&I shich pose a potential personal rights risk to persons in care.
POC Due Date: 02/17/2024
Plan of Correction
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Co-administrator to reconcile records and ensure accuracy. Self-certification to be submitted by 2/17/24.
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: 02/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2024
LIC809 (FAS) - (06/04)
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