015601483-8-2-2023-15-AS-ADEO-CUC3JZ-20230802181822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601483
Report Date: 08/02/2023
Date Signed: 08/02/2023 06:18:32 PM

Document Has Been Signed on 08/02/2023 06:18 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: 5	DATE:	08/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Justino Balintona/Licensee-Administrator		TIME COMPLETED:	06:20 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 2, 2023, at 12:00 p.m,, 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 arrived after about 20 minutes. Facility has Infection Control Plan that was submitted on 8/19/22. LPA toured the facility inside out. LPA inspected the dining room, living room, kitchen, bedrooms, bathrooms, 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 one of the bathrooms was tested, and measured at 106.7 degrees Fahrenheit. Facility conducts drills and record showed last conducted 4/22/23. LPA reviewed 4 staff and 5 residents files, and interviewed 2 staff and 2 residents. Facility does not handle residents' cash resources. Medications checked, and compared with records and doctor's orders. LPA observed the following: -at 12:14 pm, All Purpose cleaning agents, Lysol and Purell surface cleaner, Comet in ensuite bathroom cabinet without proper lock. ...continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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: ST. LOURDES HOME	FACILITY NUMBER: 015601483
	VISIT DATE: 08/02/2023

NARRATIVE

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-at 12:17 pm, transition metal plate and wood plank in the transition area between the room and ensuite bathroom detached from the flooring.
-at 12:24 pm, Lysol and Glade sprays in the common bathroom.
-at 12:27 pm, wound, peritoneal cleansers. skin protectant ointment, Glade spray and Natural Breeze spray in one of the resident bedrooms.
-at 2:25 to 2:30 pm, staff (S2, S3 and S4) has only 2 hours dementia training & no 4 hours postural support/restricted health/hospice training for 2022.
-at 4:20 pm, R5 has Melatonin OTC medication but not listed on most current list of doctor's order of medications.

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. 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.

Exit interview conducted. Appeal Rights, 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: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/02/2023 06:18 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: 08/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 for unlocked cleaning agents, disinfectants, wound& peritoneal cleansers which pose an immediate health abd safety risks to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	Licensee and staff locked all the items. In addition, licensee to in-service the staff, and submit copy of training topic with attendees signatures by 8/03/23.

Type A

Section Cited

CCR

87565(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..... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, tthe licensee did not comply with the section cited above for having medication for R5 which is not listed on the most current list of doctor's order of medication which poses an immediate health and/or personal rights risks to person in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	Licensee to check with the resident's physician, and obtain doctor's order if medication is needed. Proof to be submitted by 8/03/23.

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: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/02/2023 06:18 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: 08/02/2023

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 for the transition metal plate and wood plank detached from the flooring which pose potential safety riisks to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Licensee to have the plank and plate attached back to the flooring, and submit picture by 8/16/23.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 3 out of 4 staff not having the required annual training which poses potential safety and/or ersonal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Licensee stated he'll have the staff complete the training. Proof to be submitted by 8/16/23.

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: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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