015601313-2-14-2024-15-AS-CFOR-D2FSEZ-20240214124933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601313
Report Date: 02/14/2024
Date Signed: 02/14/2024 12:49:48 PM

Document Has Been Signed on 02/14/2024 12:49 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:	BEGONIA RESIDENTIAL CARE HOME		FACILITY NUMBER:	015601313
ADMINISTRATOR:	BOLLOSO, JOVITA		FACILITY TYPE:	740
ADDRESS:	34814 BEGONIA STREET		TELEPHONE:	(510) 429-7250
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 6	DATE:	02/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	DELIA MARTINEZ, CAREGIVER		TIME COMPLETED:	01:39 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	At approximately 9:45AM, Licensing Program Analysts (LPAs) Carol Fowler and Tonica Syess-Gibson arrived unannounced to conduct a Required 1 Year annual inspection and met with Staff Members, Delia Martinez, Caregivers. Maria Janice Vizcarra, acting Administrator arrived at approximately 11:05AM. LPA conducted a tour of the facility and observed the following: the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. There is a sufficient supply of hygiene products, paper products, and linens available for resident use. Medication was centrally stored and secure. LPA reviewed 4 of 6 resident records, which were all complete. LPA reviewed a sample of staff records. LPA reviewed 3 staff files. Staff files were complete. Administrator's Certificate# (6011284740) was current with an expiration date of 10/26/2024 The facility conducted fire and evacuation drill on 1/21/2024. Facility's fire extinguishers were last inspected 12/13/2023. Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods are within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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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Document Has Been Signed on 02/14/2024 12:49 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: BEGONIA RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601313
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health and safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2024
	Plan of Correction
1 2 3 4	Administrator agreed to complete the Emergency and Disaster Plan and submit to CCL by POC date.

Type B

Section Cited

CCR

87307(3)(E)

(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation interview, the licensee did not comply with the section cited above by having staff resting/sleeping in the closet of residents room #1 which poses a potential health and safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove the bed from the closet and send photos to CCL by POC date.

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) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/14/2024 12:49 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: BEGONIA RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601313
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 by having, scissors unlocked in the kitchen. Unlocked storage located in the backyard with paint, drill, bundo, weedeater on sideyard, unlocked glade located in room #2, unlocked All laundry detergent, Gain laundry pod Lysol wipes in an unlocked garage. A ladder unlocked in the backyard which poses a health and safety risk to persons in care.
	POC Due Date: 02/15/2024
	Plan of Correction
1 2 3 4	Administrator agreed to lock scissors, lock the storage unit in the backyard, lock laundry detergents, Lysol wipes, put ladder in storage. Administrator will email photo copies to CCL by POC date,

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) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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: BEGONIA RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601313
	VISIT DATE: 02/14/2024

NARRATIVE

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Continued from LIC809

LPAs requested the following documents to update facility file:

· Designation of Facility Responsibility (LIC 308)
· Control of Property
· Emergency Disaster Plan (LIC 610D)
· Updated Liability Insurance

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Friday, 02/21/2024.

Deficiencies observed by LPA during tour:

At 10:00AM LPAs observed 3 scissors unlocked located in the kitchen.
At 10:49AM LPAs observed glade in bedroom #2.
At 10:50AM LPAs observed unlocked scissors in china cabinet, first-aid cabinet unlocked.
At 10:55AM LPAs observed unlocked located in the garage All and Gain laundry detergent, Lysol wipes.
At 11:06AM LPAs observed unlocked storage unit with paint, drill, bundo, weed eater, wood planks and ladder in the backyard.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809 & 809C, LIC-809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to staff.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

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