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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201168
Report Date: 08/15/2023
Date Signed: 08/15/2023 02:46:51 PM


Document Has Been Signed on 08/15/2023 02:46 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:GENUINE LOVE CARE HOMEFACILITY NUMBER:
019201168
ADMINISTRATOR:DIMAGULA,HAROLD & EMELITAFACILITY TYPE:
740
ADDRESS:22947 FULLER AVE.TELEPHONE:
(510) 274-5207
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:5CENSUS: 0DATE:
08/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Staff Harold Dimaguila and Roel DimaguilaTIME COMPLETED:
02:45 PM
NARRATIVE
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On this day, August 15, 2023, at 11:35 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Harold Dimaguila and Roel Dimaguila, and informed the reason for visit. LPA spoke with Emelita Dimaguila, administrator, who can not come to the facility and authorized Harold Dimaguila to sign and receive this report.

Facility has Infection Control Plan that was submitted on August 2, 2022.

Facility currently does not have residents, and according to administrator she is planning to begin admitting beginning the month of September. 2023, and in the process of obtaining the $3M liability insurance coverage before admission of first resident.

LPA toured the facility inside out with Harold Dimaguila. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Drawer where sharps are kept was observed with lock. Cleaning supplies were kept in the garage cabinets with lock. Fire extinguisher was observed fully charge. Carbon monoxide and smoke detectors were tested and observed in operating condition. Hot water temperature in the ensuite bathroom was tested, and measured at 110.8 degrees Fahrenheit.

At 12:16 pm, LPA observed rippped shade in the backyard.


......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
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: GENUINE LOVE CARE HOME
FACILITY NUMBER: 019201168
VISIT DATE: 08/15/2023
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Administrator to submit the following updated/current documents by August 29, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)

Administrator to submit copy of $3M liability insurance coverage on or before admission of resident.

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, and any repeat violation within 12 month period may result in civil penalty.

Exit interview conducted. Appeal Rights, 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: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/15/2023 02:46 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: GENUINE LOVE CARE HOME
FACILITY NUMBER: 019201168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation

(a) 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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Based on observation, the licensee did not comply with the section cited above for ripped shade in the backyard.
POC Due Date: 08/29/2023
Plan of Correction
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Administrator to purchase a new shade and submit proof by 8/29/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3