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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601295
Report Date: 05/10/2023
Date Signed: 05/10/2023 07:01:47 PM


Document Has Been Signed on 05/10/2023 07:01 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 3, INC.FACILITY NUMBER:
015601295
ADMINISTRATOR:ESCUETA, MILANETTEFACILITY TYPE:
740
ADDRESS:23571 RONALD LANETELEPHONE:
(510) 785-0203
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:4CENSUS: 4DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH: Joana Tiglao and
Edwin Villarin, Staff		TIME COMPLETED:
07:00 PM
NARRATIVE
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On this day, May 10, 2023, at 4:30 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Joana Tiglao and Edwin Villarin. LPA called and spoke over the phone with Milanette Escueta, administrator. The administrator authorized Joana Tiglao to be with LPA during inspection, and to sign and receive this report.

Facility has an approved LIC808 Mitigation Plan but has not submitted the current/updated LIC9282 Infection Control Plan.

LPA inspected the facility inside and out including but not limited to living room. bedrooms, bathrooms, kitchen, dining area, garage, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguisher was observed fully charge with tag showed serviced March 15, 2023. Facility has carbon monoxide and smoke detectors that were tested, and observed functional. Hot water temperature in the common bathroom was tested, and measured at 109.1 degrees Fahrenheit. Facility conducts disaster drills, and records showed last conducted March 31, 2023. First aid kit inspected, and observed complete with manual.

LPA observed the following:
-at 4:59 m. collapsed boxes, toilet, mattress and bed frame in the backyard
-at 5:00 pm. side fence leaning towards neighbor's side
-at 5:30 pm, records showed Edwin Villarin fingerprinted and cleared but not associated to this facility.


......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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 3


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 3, INC.
FACILITY NUMBER: 015601295
VISIT DATE: 05/10/2023
NARRATIVE
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Administrator to submit the following current/updated documents by May 24, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. LIC9282 Infection Control Plan
5. Proof of $3M liability insurance.

Due to time constraint, LPA will come back to continue inspection and review files.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections (POCs) 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 Joana Tiglao.

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: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/10/2023 07:01 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 3, INC.
FACILITY NUMBER: 015601295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2023
Section Cited

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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.
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Administrator to do the following and submit pictures by 5/24/23:
1. Have the yard cleaned
2. Have the fence repaired/fixed.
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-This requirement is not met as evidenced:

-LPA observed the following: collapsed boxes, toilet, mattress and bed frame in the backyard; side fence leaning. These pose potential safety risks to persons in care.
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Type B
05/24/2023
Section Cited

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review.. shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Administrator to have the staff associated by 5/24/23.
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-This requirement is not met as evidenced:

-Based on record review,, the licensee did not comply with the section above for a staff not associated to this facility which poses potential safety risk to persons in care.
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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: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3