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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
015601478
Report Date:
11/14/2024
Date Signed:
11/14/2024 03:10:09 PM
Document Has Been Signed on
11/14/2024 03:10 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:
ST JOSEPH SENIOR CARE
FACILITY NUMBER:
015601478
ADMINISTRATOR/
DIRECTOR:
ZENAIDA C BAUTISTA
FACILITY TYPE:
740
ADDRESS:
6437 DAPHNE CT
TELEPHONE:
(510) 795-7603
CITY:
NEWARK
STATE:
CA
ZIP CODE:
94560
CAPACITY:
6
TOTAL ENROLLED CHILDREN:
0
CENSUS:
2
DATE:
11/14/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:
Zenaida Bautista, Licensee
TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On this day at around 9:35 am, Licensing Program Analysts (LPAs) L. Fontanilla and P. Manalo arrived unannounced to conduct an annual required inspection. LPAs met with Administrator Zenaida Bautista and explained the purpose of the visit.
During the visit, LPAs inspected the facility inside and out including but not limited to 3 resident rooms, bathroom, kitchen, dining, garage and backyard. Hot water in the kitchen measured at 144 degrees Fahrenheit. Smoke detector and carbon monoxide were tested and observed functional. Fire extinguisher was observed full and was purchased on 2/3/2024. There was sufficient supply of both perishable and non perishable foods. LPAs observed ample supply of towels, sheets, linen and hygiene products.
LPAs reviewed 2 resident and 3 staff files. LPAs interviewed two residents. First aid kit was observed complete. Facility has liability insurance. Last fire drill was conducted on 8/15/2024. Medications and Medication Administration Record (MAR) were reviewed.
Deficiencies were cited per Title 22 California Code of Regulations (see attached Lic 809D).
Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
The following records were requested to be submitted to CCL by 11/21/2024: Lic 500, Roster of Residents, updated Emergency Disaster Plan, Liability Insurance.
Exit interview was conducted. A copy of the Appeal Rights and this report were provided.
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
DATE:
11/14/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/14/2024
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
7
Document Has Been Signed on
11/14/2024 03:10 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:
ST JOSEPH SENIOR CARE
FACILITY NUMBER:
015601478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in having the Administrator's certificate expired on 12/11/2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/15/2024
Plan of Correction
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4
The Licensee designated an interim Administrator while obtaining current Administrator certificate. Required documents were sent to CCL during the visit. Licensee will submit the interim Administrator's Lic 501 by 11/15/24.
Section Cited
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having hot water measure at 144.9 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2024
Plan of Correction
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4
Hot water temperature was adjust to 111 degrees Fahrenehit during the visit. This deficiency is cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
DATE:
11/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/14/2024
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
11/14/2024 03:10 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:
ST JOSEPH SENIOR CARE
FACILITY NUMBER:
015601478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Care of Persons with Dementia
(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
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having knives and scissor unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/15/2024
Plan of Correction
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3
4
The Licensee will install a lock in the cabinet to store knives and other sharp objects and send photo proof to CCL.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
DATE:
11/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/14/2024
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
11/14/2024 03:10 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:
ST JOSEPH SENIOR CARE
FACILITY NUMBER:
015601478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having crumbs on the stove top, crumbs by the window sill, toilet with trace of feces, etc which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/30/2024
Plan of Correction
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By POC date, the facility will clean and disinfect the facility and send photo proof to LPA. LPA will come back to verify.
Section Cited
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation the licensee did not comply with the section cited above in having dusts/mold on window and sliding doors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/30/2024
Plan of Correction
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The facility will clean and disinfect window covering and walls and submit photo proof to CCL. LPA will come back to verify.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
DATE:
11/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/14/2024
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
11/14/2024 03:10 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:
ST JOSEPH SENIOR CARE
FACILITY NUMBER:
015601478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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
Based on observation, the licensee did not comply with the section cited above in having empty boxes, unused medical equipment, lots of stray cats in the backyard, etc which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/21/2024
Plan of Correction
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2
3
4
By POC date, the Administrator will dispose all unused equipment/empty boxes, trim bushes, ensure there are no stray cats in the backyard and clean up backyard and submit photo proof to CCL. LPA will come back to verify.
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.
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
DATE:
11/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/14/2024
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
11/14/2024 03:10 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:
ST JOSEPH SENIOR CARE
FACILITY NUMBER:
015601478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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 in having a side table and fan blocking exit door in Room #2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2024
Plan of Correction
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2
3
4
The Administrator removed the fan and side table during the visit. This deficiency is cleared.
Section Cited
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in failing to obtain doctor's orders for the two residents using 1/2 rail which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/21/2024
Plan of Correction
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2
3
4
The Administrator will obtain a doctor's order for the 1/2 rails and submit proof to CCL.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
DATE:
11/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/14/2024
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
11/14/2024 03:10 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:
ST JOSEPH SENIOR CARE
FACILITY NUMBER:
015601478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
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 in failing to obtain R2's updated Physician's Report which poses/posed a potential health, safety or personal rights risk to persons in care. R2 has Dementia.
POC Due Date:
11/21/2024
Plan of Correction
1
2
3
4
By POC date, the Administrator will submit to CCL R2's updated Physician's Report.
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.
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
DATE:
11/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/14/2024
LIC809
(FAS) - (06/04)
Page:
7
of
7