019200694-12-8-2023-15-AS-ADEO-CYC5V9-20231208191711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200694
Report Date: 12/08/2023
Date Signed: 12/08/2023 07:17:24 PM

Document Has Been Signed on 12/08/2023 07:17 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:	H & M HOMES STANDISH		FACILITY NUMBER:	019200694
ADMINISTRATOR:	OLIVE LOPEZ		FACILITY TYPE:	740
ADDRESS:	18543 STANDISH AVENUE		TELEPHONE:	(510) 276-2240
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	6	CENSUS: 5	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Olive 'Lyn' Lopez-Neri/Administrator		TIME COMPLETED:	07:20 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, December 8, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Olive 'Lyn' Lopez-Neri, administrator, and informed the reason for visit. LPA also met with other staff, John Louie Neri and Liwayway Manansala. Administrator submitted the facility's Infection Control Plan which LPA received on February 20, 2023. LPA toured the facility inside out with the administrator. LPA inspected the kitchen, dining area, living room, bedrooms, common and ensuite bathrooms, side yard and backyard. 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 smoke and carbon monoxide detectors that were tested, and observed functional. Facility conducts disaster drills every month, and records showed last conducted December 5, 2023. Fire extinguisher checked, observed fully charge with tag showed serviced July 26, 2023. Hot water temperature in the ensuite bathroom was tested and measured at 109.6 degrees Fahrenheit. LPA reviewed 4 staff and 5 residents files, and interviewed 2 staff and 2 residents. Medications inspected and compared with records and doctor's orders. Residents P&I checked and compared with records. LPA received the following updated/current documents: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) . .....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: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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: H & M HOMES STANDISH	FACILITY NUMBER: 019200694
	VISIT DATE: 12/08/2023

NARRATIVE

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Administrator to submit updated/current copies of the following documents by December 22, 2023:
1. $3M liability insurance certificate
2. Proof of Surety Bond coverage

The following deficiencies were observed and 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.

-at 1:45 pm, S1 does not have record of postural support training on file.
-at 1:55 pm, S2 does not have record of postural support and restricted health condition training on file.
-at 2:05pm, S3 does not have record of hospice care, postural support and restricted health condition training on file.
-from 2:45 pm to 3:25 pm, R1, R3, R4 and R5's LIC602As are over a year old.
-from 3:25 pm to 3:40 pm, LIC625 Appraisal/Needs and Services Plan for R1, R4 and R5 are over a year old.
-from 3:41 to 3:55 pm, all 5 residents have no Pre-admission Appraisal on file.
-at 4:30 pm, R1 has doctor's order for the following but the facility does have them: Acetaminophen; Cholecalciferol; Ferrous Sulfate; Folic Acid; Sennosides. Facility has the following medications on hand but no doctor's order on file: Baclofen; Dutasteride. Paroxetine on hand does not match the dosage on doctor's order on file.

Deficiencies and plan and proof of corrections were discussed with the administrator.

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: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2023 07:17 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: H & M HOMES STANDISH	FACILITY NUMBER: 019200694
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 3 staff not having the required training on file which pose a potential health, safety and/or personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator to have the training completed and submit proof by 12/22/23.

Type B

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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 5 out 5 residents not having Pre-Admission Appraisal which pose a potential health and/or personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator to complete the Pre-admission Appraisal and submit copies by 12/22/23.

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: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2023 07:17 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: H & M HOMES STANDISH	FACILITY NUMBER: 019200694
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(e)(2)

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. (2) The exact dosage. 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 for not having doctor’s order for R1’s two medications and the medication on hand of for 1 does not match the order.which poses an immediate health risk to person in care.
	POC Due Date: 12/09/2023
	Plan of Correction
1 2 3 4	Administrator stated she'll obtain doctor's order. Copy to be submitted by 12/09/23.

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. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (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 record review, the licensee did not comply with the section cited above for not having the 5 medications listed on the doctor's order for R1 which poses an immediate health risk to person in care.
	POC Due Date: 12/09/2023
	Plan of Correction
1 2 3 4	Administrator to call the doctor and check if medications are no longer needed and obtain discontinued order; otherwise obtain the medications. Proof fo be submitted by 12/09/23.

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: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2023 07:17 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: H & M HOMES STANDISH	FACILITY NUMBER: 019200694
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. 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 for R1. R4 and R5’s LIC625 Appraisal/Needs and Services Plan over a year old which pose a potential health risks to persons in c are.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator to update the LIC625s and submit self-certification by 12/22/23.

Type B

Section Cited

CCR

87458(

87458 Medical Assessment (c) The licensee shall obtain an updated medical assessment when required by the Department. 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 for R1, R3, R4 and R5's LIC602As over a year old which pose a potential health risks to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator to call the residents' doctor for appointments and submit by 12/22/23 a self-certification indicating LIC602As are updated.

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: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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