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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200462
Report Date: 01/26/2024
Date Signed: 01/26/2024 05:12:40 PM


Document Has Been Signed on 01/26/2024 05:12 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:JULIAN FAMILY CAREHOMEFACILITY NUMBER:
019200462
ADMINISTRATOR:MARCIAL D. JULIANFACILITY TYPE:
740
ADDRESS:26798 CONTESSA STREETTELEPHONE:
(510) 783-5216
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 3DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Belinda Dela Cruz/Staff TIME COMPLETED:
05:15 PM
NARRATIVE
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On this day, January 26, 2024, at 12:45 p.m, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Belinda Dela Cruz, staff, and informed the reason for visit. LPA called and spoke with Marcial Julian , licensee-administrator, over the phone who stated he cannot come to the facility, and authorized Belinda Dela Cruz to be with LPA during inspection and to sign and receive this report.

Licensee-administratro has not submitted the LIC9282 Infection Control Plan.

LPA toured the facility inside out. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has 2 in 1 smoke and carbon monoxide detectors that was tested, and observed functional. Hot water temperature in one of the bathrooms was tested, and measured at 119 degrees Fahrenheit.

LPA interviewed 1 staff and 2 residents.

LPA observed the following:
-at 1:05 p.m., scissors in kitchen cabinet without lock.
-at 1:06 p.m., 2 bottles of Nyquil cough syrup and a bottle of Enulose Solution in the refrigerator.
-at 1:20 p.m., Rubbing alcohol, bleach, laundry soap, aerosol sprays, staff's (S2) medications in unlocked garage.

...continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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: JULIAN FAMILY CAREHOME
FACILITY NUMBER: 019200462
VISIT DATE: 01/26/2024
NARRATIVE
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-at 1:40 p.m., empty laundry soap pails, pieces of wood, dirty box, broken dryer, rusted commode, 3 doors, mattress, metals, metal frame in the side yard.
-at 1:48 p.m., tarp, pieces of wood. pieces of plastic roofing, over grown weeds on the other side of the yard.
-at 3:40 p.m, licensee-administrator stated they conduct disaster drills once a year only.

Residents and staff files were not available for review. Licensee-administrator stated the files are with him.

Administrator to submit the following updated/current documents by February 9, 2024:
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 administrator over the phone.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Belinda Dela Cruz,
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/26/2024 05:12 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: JULIAN FAMILY CAREHOME
FACILITY NUMBER: 019200462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

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
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Based on observation, the licensee did not comply with the section cited above for the following which pose an immediate health and safety risks to persons in care: unlocked scissors; unlocked garage where where rubbing alcohol. laundry and cleaning supplies and staff medications are kept.
POC Due Date: 01/27/2024
Plan of Correction
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Staff locked the garage and scissors.
In addition, licensee to in-service the staff and submit proof by 1/27/24.
Type A
Section Cited
CCR
87465(h)(1)(C)
87465 Incidental Medical and Dental Care
(h) (1) (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation. the licensee did not comply with the section cited above for residents' medications in the refrigerator which pose an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 01/27/2024
Plan of Correction
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Staff locked the medications.
In addition, licensee to in-service the staff and submit proof by 1/27/24.
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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 01/26/2024 05:12 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: JULIAN FAMILY CAREHOME
FACILITY NUMBER: 019200462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

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
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2
3
4
Based on obervation,, the licensee did not comply with the section cited above for the following which poses a potential safety and/or personal rights risk to persons in care.: empty laundry soap pails, pieces of wood, dirty box, broken dryer, rusted commode, 3 doors, mattress, metals, metal frame in the side yard; tarp, pieces of wood, pieces of plastic roofing, over grown weeds on the other side of the yard.
POC Due Date: 02/09/2024
Plan of Correction
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Licensee to have the yard cleaned and submit pictures by 2/09/24.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview,, the licensee did not comply with the section cited above for personnel records not in the facility for LPA's review which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Licensee to read the Regulations and self-certify that records will be made readilty availble for review. Proof to be submitted by 2/09/24.
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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 01/26/2024 05:12 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: JULIAN FAMILY CAREHOME
FACILITY NUMBER: 019200462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above for not doing the disaster drills as required which poses/posed a potential safety and/or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Licensee to conduct disaster drill and submit copy with participants name, signatures and date conducted by 2/09/24.
In addition, licensee to self-certify that drills will be conducted every quarter.
Type B
Section Cited
CCR
87506(d)
87506 Resident Records
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above for not having the resicent records available which poses a potential personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Licensee to read the Regulations and self-certify that records will be made readily available for review. Self-certification to be submitted by 2/09/24.
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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6