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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200148
Report Date: 02/28/2024
Date Signed: 02/28/2024 07:29:36 PM

Document Has Been Signed on 02/28/2024 07:29 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:REMINGTON CARE HOME #2FACILITY NUMBER:
019200148
ADMINISTRATOR:BETH NUNEZFACILITY TYPE:
735
ADDRESS:27481 ORLANDO AVETELEPHONE:
(510) 785-9215
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 5DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Beth Nunez/Administrator TIME COMPLETED:
06:30 PM
NARRATIVE
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On this day, February 28, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with staff, Angeline Cuevas and Diana Mulfordvargas, and informed the reason for visit. LPA called and spoke over the phone with Beth Nunez, administrator. Administrator arrived at around 11:45 a.m. LPA also met with other staff, Ireneo 'Rene' Pascual.

Facility has LIC9282 Infection Control Plan which LPA obtained copy on this day.

LPA started the inspection with Diane Cuevas and administrator joined upon arrival. LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms, garage, front, side and backyard. Food were inspected and observed supplies of 2 days of perishables and 7 days of non-perishables.

Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in the ensuite bathroom was tested, and measured at 109.2 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed last conducted February 16, 2024. Fire extinguisher checked, observed fully charge with tag showed serviced February 1, 2024.

LPA reviewed 5 staff and 5 residents files, and interviewed 2 residents and 2 staff. Medications checked, and compared with records and doctor's orders. Residents' P&I checked and compared with last recorded balance.


.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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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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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148
VISIT DATE: 02/28/2024
NARRATIVE
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LPA observed the following:
-at 12:00 noon, storage in the backyard where Clorox bleach are kept was unlocked.
-at 1:05 p.m., medications of previous resident unlocked in the refrigerator.
-at 3:00 p.m., resident's (R1) LIC602 Physician's Report indicated non-ambulatory; however, R1 was observed without assistive device and able to move around without difficulty. Staff stated R1 can exit in the event of emergency.
- at 4:00 p.m., resident's (R1) frequency of administration in one of the medication label was erased. All of R1's medications not recorded on LIC622 Centrally Stored Medication and Destruction Record.
-at 4:45 p.m., resident (R2) has 6 medications listed on LIC602; however, facility has 7 medications being administered.

LPA also obtained copies of the following updated/current documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. Proof of Surety Bond coverage
4. LIC400

Administrator to submit copy of updated/current LIC610D Emergency Disaster Plan (9 pages) by March 13, 2023:

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 administrator and staff. Administrator has to leave, and authorized Ireneo 'Rene' Pascual to sign and receive this report.

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: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 02/28/2024 07:29 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2024 at 05:26 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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 in unlocked storage where Clorox bleach are kept which poses an immediate health, safety and/or personal rights risks to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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2
3
4
Staff locked the storage.
In addition, administrator to in-service the saff and submit proof by 2/29/24.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/28/2024 07:29 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2024 at 05:26 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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (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
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2
3
4
Based on record review, the licensee did not comply with the section cited above in one of R2's medications not listed on LIC602 list of medications which poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Administrator to check with the doctor if the medication is still needed, and obtain prescription. Otherwise, obtain discontinued order, and stop administering the said medication. Proof to be submitted by 2/29/24.

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: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/28/2024 07:29 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2024 at 05:26 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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication 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
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Based on observation, the licensee did not comply with the section cited above in medication of previous resident unlocked in the refrigerator which poses an immediate health, safety or personal rights risks to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Staff removed the medications.
In addition, administrator to do the following and submit proof by 2/29/24:
1. In-service the staff.
2. Ensure that medication of previous resident are properly discarded.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 02/28/2024 07:29 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2024 at 05:26 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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(4)
Client Medical Assessments
(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in R1's LIC602 not consistent with R1's current ambulatory status which poses a potential personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Administrator to obtain an updated LIC602 and submit copy by 3/13/24.
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R1's medications not listed on LIC622 which poses a potential personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Administrator to have the LIC622 completed and submit self-certificaiton by 3/13/24.
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: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 02/28/2024 07:29 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2024 at 05:53 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: REMINGTON CARE HOME #2
FACILITY NUMBER: 019200148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(4)
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(4) No person other than the dispensing pharmacist shall alter a prescription label.

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 prescription label of 1 of R1's medications erased which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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2
3
4
Administrator to read the Regulations and ensure no prescription labels erased. Self-certification to be submitted by 3/13/24.
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: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024


LIC809 (FAS) - (06/04)
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