397005336-11-19-2024-27-AS-APAA-DB6QWM-20241119113210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005336
Report Date: 11/19/2024
Date Signed: 11/19/2024 11:32:23 AM

Document Has Been Signed on 11/19/2024 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	RM UGALE CARE HOME		FACILITY NUMBER:	397005336
ADMINISTRATOR/ DIRECTOR:	MAGSAYO-UGALE, MAYBELYN		FACILITY TYPE:	740
ADDRESS:	110 E. MT. DIABLO AVENUE		TELEPHONE:	(209) 836-5215
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	11/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Maybelyn Magsayo-Ugale		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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 11/19/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Staff Members (SM), Everly R. Estella and Cathleen Maghinay and explained the purpose of the visit. LPA asked the SM Estella and SM Magaimay to call the Facility Designated Administrator (FDA), Maybelyn Ugale to inform them that CCL was present. Shortly after, LPA Pascua met with Current census was 3. A brief interview with SM Estella and Magaimay were conducted. LPA reviewed 3 resident files. It was observed that 2 out 3 residents did not have current physicians reports or needs and services plans on file. LPA reviewed 2 staff files. 2 out 2 staff files did not have a First Aid/CPR certificate on file. 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. A fire extinguisher located in the kitchen was observed to be last serviced on 05/28/2024 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.

Lisa Rios	TELEPHONE: (916) 969-9685
Arielle Pascua	TELEPHONE: (916) 862-5907
	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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 11/19/2024 11:32 AM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RM UGALE CARE HOME	FACILITY NUMBER: 397005336
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not ensure that 2 out 2 resident files reviewed had a current physicians report on file. This poses an potential health, safety, and personal rights risks to persons in care.
	POC Due Date: 12/20/2024
	Plan of Correction
1 2 3 4	Licensee shall provide a statement of correction and acknowledgement to the LPA by the POC date. In addition, Licensee shall conduct provide copies of annual medical assessments for 2 out 2 residents by the POC date.

Section Cited

(6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section above in by not ensure that 2 out 2 resident files did not have a current reappraisal which poses a potential health, safety, and personal rights risks to persons in care.
	POC Due Date: 12/20/2024
	Plan of Correction
1 2 3 4	Licensee shall provide a statement of correction and acknowledgement. Licensee shall conduct reappraisals for all residents and provide a copy to the LPA 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.

Lisa Rios	TELEPHONE: (916) 969-9685
Arielle Pascua	TELEPHONE: (916) 862-5907
	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/19/2024 11:32 AM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RM UGALE CARE HOME	FACILITY NUMBER: 397005336
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not ensuring that 2 out 2 staff members do not have a current First Aid and/or CPR on file. This poses an immediate, health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2024
	Plan of Correction
1 2 3 4	Licensee shall provide a statement of correction and acknowledgement to this LPA by POC date. First aid and/or CPR must be sent to the LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lisa Rios	TELEPHONE: (916) 969-9685
Arielle Pascua	TELEPHONE: (916) 862-5907
	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RM UGALE CARE HOME	FACILITY NUMBER: 397005336
	VISIT DATE: 11/19/2024

NARRATIVE

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A tour of the yard was conducted. Perimeter fence and gates were observed to be in good repair with no hazards present.

The following forms were requested to be submitted:
-LIC 500
-LIC 408
-LIC 610e

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, 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: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 11/19/2024 11:32 AM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RM UGALE CARE HOME	FACILITY NUMBER: 397005336
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(a) Licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall ensure that all direct care staff, described in Section 87706(a)(1), who provide care to residents with dementia, meet the following training requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in by not ensuring that 2 out 2 staff members did not have dementia related training. This poses an immediate health, safety and personal rights risks to persons in care.
	POC Due Date: 11/20/2024
	Plan of Correction
1 2 3 4	Licensee shall provide a statement of correction and acknowledgement to the LPA by POC date. A copy of all staff training must be sent to the LPA by 12/20/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lisa Rios	TELEPHONE: (916) 969-9685
Arielle Pascua	TELEPHONE: (916) 862-5907
	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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