<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440339
Report Date: 06/08/2023
Date Signed: 06/08/2023 04:52:09 PM

Document Has Been Signed on 06/08/2023 04:52 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:PIROUNAKIS, INC.FACILITY NUMBER:
011440339
ADMINISTRATOR:MARY PIROUNAKISFACILITY TYPE:
735
ADDRESS:17031 RAGLAND ST.TELEPHONE:
(510) 276-2301
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 12CENSUS: 11DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Mary Pirounakis/Administrator
and Margaret 'Rita' Revill/Co-administrator		TIME COMPLETED:
04:55 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 this day, June 8,, 2023, at 11:25 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Marie Lopez. Mary Pirounakis, administrator, and Margaret 'Rita' Revill, co-administrator, arrived after few minutes. LPA also met with other staff, Perla Ibanez and Michael Revill.

LPA toured the facility with the administrator. LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining and living areas, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced February 16, 2023. Facility has 2 in 1 carbon monoxide and smoke detector that was tested and observed functional. Hot water temperature in one the common bathrooms was tested and measured at 108 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed last conducted May 9, 2023.

LPA reviewed 5 residents and 5 staff files, and interviewed 2 residents and 2 staff. Medications were checked and compared with records. Residents' cash resources reconciled with records.

During records review, LPA observed the following:
-At 2:50 pm, resident (R1) has no LIC622 Centrally Stored Medication and Destruction Record. Doctor's order for Vitamin D3 is 2000 IU but Medication Administration Record (MAR) showed R1 is given only 1 tablet 1000 IU.
-At 3:30 pm, facility has one medication on facility's hand for resident (R5) but no doctor's order on file.


......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339
VISIT DATE: 06/08/2023
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
26
27
28
29
30
31
32
LPA received the following updated documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage
5. LIC9282 Infection Control Plan

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator and co-administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/08/2023 04:52 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/08/2023 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
80075 Health Related Services
(b)(6) (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section above for 1 out of 5 residents not having doctor’s order on file for 1 of the medications which poses immediate health risk to person in care.
POC Due Date: 06/09/2023
Plan of Correction
1
2
3
4
Administrator stated she'll obtain doctor's order. Copy to be submitted by 6/08/23.
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
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/08/2023 04:52 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/08/2023 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(B)
80075 Health Related Services
(b)(5) (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
-Based on records review, the licensee did not comply with the section above for 1 out of 5 residents given lesser dosage of prescribed Vitamins which poses potential health risk to person in care.
POC Due Date: 06/15/2023
Plan of Correction
1
2
3
4
Effective immediately, administrator to have complete dosage of Vitamins administered to the resident.
Copy of MAR to be submiited by 6/15/23.
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section above for 1 out of 5 residents not having LIC622 on file.
POC Due Date: 06/15/2023
Plan of Correction
1
2
3
4
Administrator to do the LIC622 for R1 and submit by 6!/15/23 a self-certification it's completed.
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
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4