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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200750
Report Date: 02/12/2025
Date Signed: 02/12/2025 05:32:14 PM

Document Has Been Signed on 02/12/2025 05:32 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:SCOTT VILLAFACILITY NUMBER:
019200750
ADMINISTRATOR/
DIRECTOR:		JONABELLE TOLENTINOFACILITY TYPE:
740
ADDRESS:1560 MIDDLE LANETELEPHONE:
(510) 782-7833
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 35TOTAL ENROLLED CHILDREN: 0CENSUS: 34DATE:
02/12/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Lulin 'Lucy' Wu/Back-up AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
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While at the facility conducting an investigation of a complaint (Control # 15-AS-20250204131826) and upon review of resident's (R1) file, LPA observed R1's medications on the medication bottles were discarded to a container. R1 was discharged from the facility effective 1/29/25. The Medication Destruction page of the LIC622 Centrally Stored Medication and Destruction Record was not completed.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date may result civil penalty.

Deficiency and plan and proof of correction were discussed with Lulin 'Lucy' Wu, back-up administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201
DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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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Document Has Been Signed on 02/12/2025 05:32 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: SCOTT VILLA
FACILITY NUMBER: 019200750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2025
Section Cited
CCR
87465(i)

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87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record ...
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BUA stated she'll conduct in-service training.
In addition, BUA to complete the LIC622's Destruction page.
Proof to be submitted by 2/26/25.
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shall be destroyed in the facility by the facility administrator and one other adult who is not a resident.....

-This requirement is not met as evidenced by:
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Type B
02/27/2025
Section Cited
CCR87565(i)

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CONTINUATION:
-Based on records review, interview and observation, the licensee did not comply with the section above in not documenting on LIC622 the medications of R1 that were to be disposed.
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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.
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201

DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025

LIC809 (FAS) - (06/04)
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