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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200670
Report Date: 06/10/2021
Date Signed: 06/10/2021 02:59:50 PM

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:ACAPULCO SENIOR CARE HOMEFACILITY NUMBER:
019200670
ADMINISTRATOR:KA, NINFACILITY TYPE:
740
ADDRESS:14160 ACAPULCO ROADTELEPHONE:
(510) 924-7457
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:6CENSUS: 2DATE:
06/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Joyce RodriguezTIME COMPLETED:
03:15 PM
NARRATIVE
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On 6/10/2021 at 12:31pm, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Staff S1 and explained the purpose of the visit. Administrator Joyce Rodriguez arrived at approximately 12:40pm.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and backyard. LPA observed COVID-19 signage in the facility including physical distancing posted. A hand washing poster was posted in common bathroom.

LPA observed food and paper supplies are sufficient. Common areas are disinfected throughout the day.

LPA observed laundry detergent and bleach in unlocked laundry room accessible to residents. LPA observed bleach in common bathroom accessible to residents. LPA observed Lysol on shelf in kitchen accessible to residents. LPA observed that that the facility does not have working carbon monoxide detectors. PIN 21-12-ASC states "All staff are required to wear face coverings (unless required to wear an N95 respirator". However, Administrator was observed in facility without mask in common areas. Administrator stated facility is not conducting COVID-19 surveillance testing per PIN 21-28-ASC.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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
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: ACAPULCO SENIOR CARE HOME
FACILITY NUMBER: 019200670
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Person with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed laundry detergent and bleach in unlocked laundry room, LPA observed bleach in common bathroom, and LPA observed Lysol on shelf in kitchen accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2021
Plan of Correction
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Administrator agrees to lock all laundry detergent and cleaning supplies in cabinet and submit a picture to CCL by POC date.
Type A
Section Cited
HSC
1503.2
1503.2 Carbon monoxide detectors required; inspection
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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. LPA observed no working carbon monixide detectors in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2021
Plan of Correction
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Administrator agrees to install a working carbon monoxide detector and submit a picture to CCL by POC date.
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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: ACAPULCO SENIOR CARE HOME
FACILITY NUMBER: 019200670
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)(2)
87405
Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

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. Administrator stated facility is not conducting COVID-19 surveillance testing which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2021
Plan of Correction
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Administrator agrees to send CCL a COVID-19 surveillance testing schedule of all staff for the remaining month of June 2020 and July 2020 by POC date.
Type B
Section Cited
CCR
87468.1(a)(2)
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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. PIN 21-12-ASC states "All staff are required to wear face coverings (unless required to wear an N95
respirator". However, LPA observed administrator not wearing a mask in common area which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2021
Plan of Correction
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By POC date Administrator agrees to review PIN 21-12-ASC and send a copy of self-certification document 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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3