015601483-8-7-2024-15-AS-ADEO-D7X3N3-20240807182317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601483
Report Date: 08/07/2024
Date Signed: 08/07/2024 06:23:29 PM

Document Has Been Signed on 08/07/2024 06:23 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. LOURDES HOME		FACILITY NUMBER:	015601483
ADMINISTRATOR:	BALINTONA, JUSTINO		FACILITY TYPE:	740
ADDRESS:	1626 ASHBURY LANE		TELEPHONE:	(510) 265-0818
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Justino Balintona/Licensee-Administrator		TIME COMPLETED:	06:30 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	On this day, August 7, 2024, at 10:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Warlita Romero and Margarita Corazon Mariano. LPA called and spoke over the phone with Justino Balintona, licensee-administrator, and informed the reason for visit. LPA asked, and licensee authorized Warlita Romero to be with LPA during inspection. Licensee-administrator arrived after about 25 minutes. Facility has Infection Control Plan that was submitted on 8/19/22. LPA started inspection with Margarita Corazon Mariano and continued with administrator. LPA inspected the dining room, kitchen, bedrooms, bathrooms, living room, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked. Facility has smoke and carbon monoxide detectors that were tested, and observed functional. Hot water temperature in the common bathroom was tested, and measured at 108 degrees Fahrenheit. Facility conducts drills and record showed last conducted 7/08/24. LPA reviewed 4 staff and 5 residents files, and interviewed 2 staff. Facility does not handle residents' cash resources. Medications checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. LPA observed the following: -at 10:42 am, refrigerator's vegetable crispers with mold, rotten bitter melon leaves, rotten asparagus and lettuce. ...continued on 809C (page 2)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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: ST. LOURDES HOME	FACILITY NUMBER: 015601483
	VISIT DATE: 08/07/2024

NARRATIVE

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-at 10:52 am, Voltaren, athlete's foot and hydrocortisone ointments in the drawer in one of the resident's room, and CaRezz continent and Chloehexine gluconate rinse in the closet in this resident's room.
-at 11:07 am and 11:09 am, broken drawer knobs in 2 resident rooms and missing drawer knob in the drawer by the hallway.
-at 11:10 am, razors in the common bathroom.
-at 11:12 am, bathroom cabinets with heavily peeled varnish and soiled bath tub.
-at 11:17 am, ensuite bathroom's shower door with mildew.
-at 11:20 am, Raid insect killer, gallons of liquid sanitizer, expired canned foods and rotten cauliflower in unlocked storage in the backyard.
- at 11:24 am, automotive agents, bug and windshield cleaner, stain remover, rusted metal cart in the backyard.
-at 11:38 am, staff's medications in the living room.
-at 1:49 pm, resident's (R2) LIC602A Physician's Report revealed R2 is bedridden and dependent on others with all activities of daily living (ADLs). LPA observed R2 unable to reposition on his own.
-at 2:50 pm, resident (R1) has doctor's order for Mupirocin (3x/day), Asprin 81 mg (1 tab/day), Colchicine, but facility does not have these meds. Acetaminophen 315 mg (PRN) but at facility's hand is 500 mg. HydrAlazine order is 50 mg 3x/day but at facilty's hand is 25 mg 3x/day. Quetiapine 25 mg 1 tablet daily but label on this medication is 2x/day. Vitamin D3's order is 25 mcg (1,000 IU) but on hand is 50 mcg (2,000 IU) and facility administers 50 mcg daily. Voltaren, multi Vitamins & stool softener have no order on file.
-at 3:35 pm, resident (R4) has order for 2.5 mg Lisinopril but facility does not have this medication.
-at 4:00 pm, resident (R5) has discontinued order for Lisinopril 20 mg but facility is administering this medication. Has order for Albuterol 2.5 mg but facility does not have this medication. Has Quetiapine 25 mg but no doctor's order on file.

....continued on 809C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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: ST. LOURDES HOME	FACILITY NUMBER: 015601483
	VISIT DATE: 08/07/2024

NARRATIVE

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LPA received the following updated/current documents on this day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 87202(a)(2). 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 the licensee-administrator.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/07/2024 06:23 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. LOURDES HOME	FACILITY NUMBER: 015601483
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons 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 in having bedridden resident (R2) but facility is not licensed nor have bedridden fire clearance which poses an immediate safety and/or personal rights risk to persons in care.
	POC Due Date: 08/08/2024
	Plan of Correction
1 2 3 4	Administrator stated will have the resident move out. Proof to be submitted by 8/08/24.

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the following which poses an immediate health, safety and/or personal rights risk to persons in care: Raid insect killer, gallons of liquid sanitizer in unlocked storage in the backyard; automotive agents, bug and windshield cleaner, stain remover in the backyard; staff's medications in the living room; razors in the bathroom; ointments and peritoneal cleanser in resident's room
	POC Due Date: 08/08/2024
	Plan of Correction
1 2 3 4	Staff locked the items. In addition, administrator in-service the staff and submit copy of training topic with attendees signatures by 8/08/24.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 08/07/2024 06:23 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. LOURDES HOME	FACILITY NUMBER: 015601483
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 the following which pose an immediate health and/or personal rights risk to persons in care: rotten bitten melon leaves, asparagus, lettuce and cauliflower; expired canned good.
	POC Due Date: 08/08/2024
	Plan of Correction
1 2 3 4	Staff threw the items. In addition, administrator in-service the staff and submit copy of training topic with attendees signatures by 8/08/24.

Type A

Section Cited

CCR

87465(e)

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, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review, the licensee did not comply with the section cited above in R1's Vitamins, ointments and stool softener, and R5's Quetiapine with no doctor's orders which pose an immediate health and/or personal rights risks to persons in care.
	POC Due Date: 08/08/2024
	Plan of Correction
1 2 3 4	Administrator to obtain doctor's orders and submit copies; otherwise, stop the administration and submit proof by 8/08/24.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 08/07/2024 06:23 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. LOURDES HOME	FACILITY NUMBER: 015601483
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/ or personal rights risks to persons in care: ensuite bathroom's shower door with mildew; cabinets with heavily peeled varnish and soiled bathtub in the common bathroom; refrigerator's vegetable crispers with mold; broken drawer knobs in 2 resident rooms and missing drawer knob in the drawer by the hallway; rusted metal cart in the yard
	POC Due Date: 08/21/2024
	Plan of Correction
1 2 3 4	Staff cleaned the vegetable crispers. In addition, administrator to do the following and submit pictures by 8/21/24: (1) Have the shower door and bathtub cleaned.; (2) Have the cabinets re-varnished.; (3) Replace the drawer knobs.; (4) Dispose the metal cart.

Type B

Section Cited

CCR

87615(a)(5)

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. 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 in R2 who is dependent on staff with all ADLs which poses potential health, safety and/or personal rights risks to person in care.
	POC Due Date: 08/21/2024
	Plan of Correction
1 2 3 4	Administrator stated he'll have R2 move out and submit proof.

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) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 08/07/2024 06:23 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. LOURDES HOME	FACILITY NUMBER: 015601483
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility…… (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review, the licensee did not comply with the section cited above in the following which pose an immediate health and/or personal rights risks to persons in care: R1 has doctor's order for 3 medications but facility does not have them; some of R1's medication dosages and frequency of adminstration on the labels do not match the doctor's orders; R4 has order for 1 medication which facility does not have on hand; R5 has discontinued order for Lisinopril and facility administering this medication; R5 has order for Albuterol 2.5 mg but facility does not have this medication
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	Administrator to obtain correct doctor's orders, obtain the medications and/or discontinued orders, and submit copies by 8/08/24.

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) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

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