079200787-2-20-2024-15-AS-CFOR-D2MTR9-20240220135711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200787
Report Date: 02/20/2024
Date Signed: 02/20/2024 02:01:03 PM

Document Has Been Signed on 02/20/2024 02:01 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:	DIANA'S CARE HOME		FACILITY NUMBER:	079200787
ADMINISTRATOR:	REANO-AQUINO, GRACE		FACILITY TYPE:	740
ADDRESS:	27402 MANON AVENUE		TELEPHONE:	(510) 786-9982
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	35	CENSUS: 35	DATE:	02/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Grace Reano-Aquino, Administrator		TIME COMPLETED:	02:30 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 2/20/2024 at 9:45am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Grace Reano-Aquino, Administrator. The Administrator currently holds a certificate (#6000611740) that expires on 07/07/2025. The facility’s fire clearance was approved for thirty five (35) residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, back and side yard. The facility consists of nineteen (19) total bedrooms, and six (6) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/20/2023. Emergency Disaster Plan was posted. First aid kit was observed to be complete. LPA reviewed seven (7) staff files and nine (9) resident file which were all found to be complete. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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 02/20/2024 02:01 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: DIANA'S CARE HOME	FACILITY NUMBER: 079200787
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having chemicals such as Raid, Lysol and Clorox wipes unlocked at an unattended reception area which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/21/2024
	Plan of Correction
1 2 3 4	Administrator agreed to lock and keep cabinet locked at all times. DEFICIENCY CLEARED DURING VISIT.

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked pre-poure medication in resident room ##3 which poses an immediate health and safety risk to persons in care. Staff locked medication.
	POC Due Date: 02/21/2024
	Plan of Correction
1 2 3 4	Administrator agreed to keep all medication locked in medication closet at all times. Staff locked medication. DEFICIENCY CLEARED DURING VISIT.

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) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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: DIANA'S CARE HOME	FACILITY NUMBER: 079200787
	VISIT DATE: 02/20/2024

NARRATIVE

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Continue from LIC 809

LPA observed the following deficiencies:

· At 10:10am, LPA observed Raid, Lysol, Clorox wipes unlocked at an unattended reception area.
· At 10:14am, LPA observed pre-poured medication located in resident room #3.
· At 10:49am, LPA observed a shed used for staff living quarters.
· At 10:54am, LPA observed locked gate.

LPA requested the following documents to be submitted to CCLD by 2/29/2023.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate $500.00 civil penalty will be assessed on today's date for associations.*

Exit interview conducted. A copy of the LIC421BG, this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/20/2024 02:01 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: DIANA'S CARE HOME	FACILITY NUMBER: 079200787
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(I)(1)(2)

Care of Persons with Dementia: The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates. (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having a pad lock on the side yard gate at the facility, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/21/2024
	Plan of Correction
1 2 3 4	The Administrator had staff to remove the pad lock. DEFICIENCY CLEARED DURING VISIT. CIVIL PENALTY ASSESSED.

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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/20/2024 02:01 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: DIANA'S CARE HOME	FACILITY NUMBER: 079200787
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(2)(B)

87307 Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a bed placed in the living room that staff are using for sleeping, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove the bed and staff personal belongings from the shed and submit photos to CCL 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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