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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200462
Report Date: 04/04/2024
Date Signed: 04/04/2024 07:04:45 PM


Document Has Been Signed on 04/04/2024 07:04 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:
04/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Belinda Dela Cruz/Staff TIME COMPLETED:
07:15 PM
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While at the facility investigating a complaint (Control # 15-AS-20240327144832), Licensing Program Analyst (LPA) Delmundo learned that the administrator yelled at resident (R1) which during interview, the administrator admitted to yelling when R1 becomes verbally abusive to the caregivers.

During interviews and review of records, LPA observed the following:
1. Unlocked medication in resident's (R1) room. The administrator stated R1 wants to keep the medication in the room and administer own medication, Review of LIC602A Physician's Report showed R1 can not administer own medications.
2. R1's LIC602A showed ambulatory when Pre-placement Appraisal showed non-ambulatory and R1uses wheel chair to move around and about.
3. R1's 2 medications run out; one of which with filled date 1/30/24 (quantity: 30) and the other one with filled date 2/04/24 (quantity; 30) and started administration on 2/18/24 and 2/10/24 respectively.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87465(h)(1)(C). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies, civil penalty and plan and proof of corrections were discussed with the administrator over the phone who authorized Belinda Dela Cruz, staff, to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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 3


Document Has Been Signed on 04/04/2024 07:04 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: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2024
Section Cited
CCR
87465(h)(1)(C)

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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.... the medications are determined by either a physician......or Department to be a safety hazard to others.

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Administrator to have the medication locked and in-service the staff,

A $250.00 civil penalty is assessed.
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-This requirement is notmet as evidenced by:
-Based on observation and interview, the licensee did not comply with the section above for medication in resident's room which poses an immediate risks to persons in care. This is a repeat violation, First citation was issued on 1/26/24.
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Type A
04/05/2024
Section Cited
CCR87465(a)(4)

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87465 Incidental Medical and Dental Care
(a) .....(4) The licensee shall assist residents with self-administered medications as needed.

-This requirement is not met as evidence by:
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Administrator to obtain the medicaitons, and submit proof by 4/05/24.
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-Based of records review, the licensee did not comply with the section above for 2 of R1's medicatons run out which pose immediate health risks to person in care.
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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: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/04/2024 07:04 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: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2024
Section Cited
CCR
87458(b)(5)

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87458 Medical Assessment
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory.... The assessment shall indicate whether nonambulatory status is based upon the resident’s physical condition,
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Administrator to have the LIC602A updated and submit copy by 4/18/24.
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... mental condition or both.
-This requirement is not met as evidenced by:
-Based on records review, the licensee did not comply with the section above in R1's LIC602A ambulatory status not consistent with R1's physical condition which poses health risk to person in care
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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: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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