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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005336
Report Date: 10/16/2023
Date Signed: 10/16/2023 05:11:25 PM


Document Has Been Signed on 10/16/2023 05:11 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:RM UGALE CARE HOMEFACILITY NUMBER:
397005336
ADMINISTRATOR:MAGSAYO-UGALE, MAYBELYNFACILITY TYPE:
740
ADDRESS:110 E. MT. DIABLO AVENUETELEPHONE:
(209) 836-5215
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:6CENSUS: 5DATE:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maybelyn Ugale TIME COMPLETED:
01:30 PM
NARRATIVE
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On 10/16/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member (SM), Shamima Ali and explained the purpose of the visit. LPA asked that SM Ali call the Facility Designated Administrator (FDA), Maybelyn Ugale, and inform her that CCL was present at this time. Shortly after, LPA met with FDA Ugale and explained the purpose of the visit. There were two other staff members present at the facility, Cathleen Maghinay and Esterlita Chua.

This facility is licensed to serve 6 residents who are 60 or older. 6 out 6 residents may be non-ambulatory. This facility also holds a Dementia Plan on file and has a hospice waiver for 2.

Upon arrival at the facility, it was found that S1 was not currently associated to the facility.

LPA asked to review staff and resident files. LPA was informed that staff did not know where files were, however, the facility administrator would be able to find the files when she arrives at the facility. LPA informed the facility that files shall be readily available upon request. LPA reviewed 3 resident files. 3 out of 3 resident files were observed not to have a current Appraisal form and did not have a Pre-Appraisal. 1 out 3 resident files did not have a current physicians report on file. LPA reviewed 3 staff files. 3 out 3 staff files were observed to be incomplete. Upon reviewing facility files, LPA observed FDA Ugale take several sharps from an open drawer and place them into a locked cabinet.
The current administrator does not have a current active administrator certificate, however, the administrator has provided the department the proper renewal forms prior to their expiration date on 09/17/2023. The department reviewed a payment on 09/08/2023.
A tour of the facility was conducted.

A tour of the kitchen was conducted. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply at this time. Knives were locked and made inaccessible in a separate closet away from the kitchen at this time.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336
VISIT DATE: 10/16/2023
NARRATIVE
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 A fire extinguisher located in the kitchen was observed to be last serviced on 06/15/2023 by Armor Fire Inc and is in compliance at this time. Smoke detectors and carbon monoxide was observed to be in good repair.

Medication was observed to be in a locked cabinet near the kitchen. Along with the administrator, LPA reviewed and compared resident medication to medication dispensing logs.

A tour of 3 resident bedrooms were conducted. LPA observed that in 2 out 3 resident bedrooms did not have a chest of drawers sufficient to meet the resident's needs. A tour of a staff bedroom was also conducted.
A tour of 2 resident bathrooms were conducted. Hot water temperature was taken to ensure that it was dispensed at the correct temperature at this time. LPA osberved water damage on the corner of the baseboard near the shower. Additionally, scuffs from the resident's belongings were along the walls.
A linen closet was identified. Linen was observed to be in sufficient for residents in care.
A tour of the garage was conducted. Washer and dryer were identified. Toxins, laundry detergent and other cleaning supplies were observed to be locked and made inaccessible.
A tour of the yard was conducted. Perimeter fence and gates were observed to be in good repair with no hazards present.

Based on the observations made on this visit, an immediate civil penalty of $500 was assessed for a violation of Section 80019(e)(2). This civil penalty was based on criminal record clearance transfer violation. The Licensee stated that S1 and S2 was working prior to obtaining her criminal record clearance transfer and has not done the paperwork prior to working at this facility.

As a result of this visit, the following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

An exit interview was conducted. A copy of the 809, 809-C, 809-D, LIC421BG and appeal rights were printed and a copy was given to the facility designated Administrator, Maybelyn Magsayo-Ugale. The licensee was informed that a failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/16/2023 05:11 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 by not ensuring that S1 was associated to the facility. This poses an immediate health, safety, and personal rights risk to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
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Licensee shall provide a statement of acknowlegement stating that they have read and understood Section 87355(e)(3). Licensee stated that S1 will be associated by the POC date. An immediate civil penalty of $500 is being assessed.
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

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 by ensuring that 3 out 3 staff members did not have a current First Aid Certificate. This poses an immediate health, safety or personal rights risks to persons in care.
POC Due Date: 10/17/2023
Plan of Correction
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Licensee shall conduct first aid training for all staff members who do not have a current certificate by the POC date. Copies of first aid training shall be submitted to the LPAs email.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 10/16/2023 05:11 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

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 by not ensuring that 3 out 3 residents did not have a pre-admission appraisal. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Licensee shall provide a statement of acknowledgement that they have read and understanding the section cited above by the POC date.
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:

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 above by ensuring that all staff did not have current Dementia training. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Licensee shall ensure that on-the-job training shall be provided to all staff on an annual basis. Licensee shall conduct training by POC date. A copy of training, along with information discussed, trainer, names of trainees shall be sent to the LPA by the 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/16/2023 05:11 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

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 by ensuring that 3 out 3 residents have a current appraisals conducted. This poses an potential health, safety, and personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Licensee shall provide a statement of acknowledgement and a plan of correction to ensure that appraisals are conducted on an ongoing basis by the POC date.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5