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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601295
Report Date: 05/17/2023
Date Signed: 05/17/2023 06:56:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/17/2023 06:56 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:
05/17/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Soledad Escueta/Assistant Administrator
and Milanette Escueta/Administrator		TIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on May 10, 2023. LPA met with staff, Joana Tiglao and Soledad Escueta, assistant administrator. LPA informed the reason for visit. Milanette Escueta, administrator, arrived after several hours.

LPA reviewed 4 resident and 5 staff files, and interviewed 2 residents and 2 staff.

On this same day, LPA received copies of current administrator certificate of the following: Milanette Escueta and Soledad Escueta

LPA observed the following:
-staff (S2 and S4) have not completed the required 20 hours annual training for 2022.
-staff (S2) and S4) administer medications to residents but only have 2 hours medications training on file for 2022.
-staff (S2) and S4) do not have the required 8 hours annual dementia training and required 4 hours annual training of which shall be specific to postural supports, restricted health conditions, and hospice for 2022.
-at 4:30 pm, residents' (R1, R2 & R4) reappraisal not current.
-at 5:15 pm, residents (R1, R2, R3, R4) do have doctor's order of medications on file.


......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
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: ESCUETA CARE HOME 3, INC.
FACILITY NUMBER: 015601295
VISIT DATE: 05/17/2023
NARRATIVE
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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.

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: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/17/2023 06:56 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: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2023
Section Cited
CCR
87465(e)

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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.,....
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Administrator to obtain copies of doctor's order and submit copies by 5/18/23.
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-This is not met as evidenced by:

-Based on records review, the licensee did not comply with the section above for 4 out of 4 residents not having doctor's orders on file which pose immediate health risks 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: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/17/2023 06:56 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: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
CCR
87463(a)

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87463 Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.....
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Administrator to do the reappraisals, and submit a self-certification by 5/31/23 indicating it's completed.
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-This is not met as evidenced by:
-Based on records review, the licensee did not comply with the section above for 3 out of 4 residents not having a current re-appraisal on file which pose potential health and personal right risks to persons in care.
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Type B
05/31/2023
Section Cited
HSC1569.625(2)

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§1569.625 Staff training; legislative findings; contents (2).... training requirements shall also include an additional 20 hours annually, 8 hours of which shall be dementia care training, ... and four hours of which shall be specific to postural supports, restricted health conditions, and hospice
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Administrator to have the staff complete the required training and submit proof by 5/31/23.
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-This is not met as evidenced by:
-Based on records review, the licensee did not comply with the section above for 2 out of 5 staff with incomplete required annual training on file which poses potential safety and personal right risks 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: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/17/2023 06:56 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: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
HSC
1569.69(b)

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§1569.69 Employees assisting residents with self-administration of medication; training requirements: (b) Each employee .... who continues to assist with the self-administration of medicines, shall also complete four hours of in-service training on medication-related issues in each.....
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Administrator to have the staff complete the training and submit proof by 5/31/23.
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.....succeeding 12-month period.
-This is not met as evidenced by:

-Based on records review, the licensee did not comply with the section above for 2 staff not having the total required number of annnual medication training on file.
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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: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
LIC809 (FAS) - (06/04)
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