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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441162
Report Date: 01/30/2024
Date Signed: 01/30/2024 07:21:57 PM

Document Has Been Signed on 01/30/2024 07:21 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:GALICIA'S TULIP CARE HOME #2FACILITY NUMBER:
011441162
ADMINISTRATOR:GALICIA, CONSUELOFACILITY TYPE:
740
ADDRESS:745 CINNAMON COURTTELEPHONE:
(510) 783-4888
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 5DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Consuelo 'Connie' Galicia/Licensee-Administrator
and Rolando Galicia/Licensee 		TIME COMPLETED:
07:25 PM
NARRATIVE
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On this day, January 30, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Ruth Carreon, Perlita Peria and Nimfa Boado, and informed the reason for visit. LPA called and spoke over the phone with Consuelo 'Connie' Galicia, licensee-administrator, who authorized Ruth Carreon to be with LPA in touring the facility. Administrator and Rolando Galicia, licensee, arrived at 12:20 p.m.

Facility has LIC9282 Infection Control Plan that was submitted on 12/30/22 along with Monkeypox Infection Control Plan.

LPA toured the facility inside out with Ruth Carreon. LPA inspected the kitchen, dining area, staff quarter/office, bedrooms, bathrooms, front and backyards. Food supplies were observed good for 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 one of the bathrooms was tested and measured at 116.2 degrees Fahrenheit.

LPA reviewed 4 staff and 5 residents records, and interviewed 2 staff and 2 residents. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored and Medication Records. Facility does not handle residents' cash resources.

LPA observed the following:
-at 11:34 to 11:37 a.m., residents and staff medications unlocked in the staff quarter/office.
-at 10:40 a.m., residents' medications in the kitchen counter and refrigerator.

.....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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 10
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: GALICIA'S TULIP CARE HOME #2
FACILITY NUMBER: 011441162
VISIT DATE: 01/30/2024
NARRATIVE
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Page 2

-at 11:41 a.m., expired salad dressing in the refrigerator (expiration: 9/27/22).
-at 11:49 a.m., medications in one of residents rooms.
-at 11:55 a.m., ointments and saline solution in another residents' room.
-at 11:57 a.m., denture cleaners in residents' ensuite bathroom.
-at 12:02 p.m., Comet, Lysol and Mr. Clean cleaning agents and fabric disinfectant in the common bathroom cabinet.
- trash cans in the staff quarter and bathrooms with no lids.
-at 12:27 p.m., fire extinguisher fully charge; however tag showed last serviced 4/08/22.
-at 2:00 p.m., LPA asked and per administrator they have not conducted disaster drill since COVID-19 pandemic.
-at 2;15 p.m., staff (S3 and S4) have no LIC503 Health Screening and TB test on file.
-at 2:57 to 3:15 p.m., residents (R2 and R3) LIC602A Physician's Report and LIC625 Appraisal/Needs and Services Plan are over a year old.
-at 3:30 p.m., resident (R4) does not have Pre-admission Appraisal on file.
-at 3:45 p.m., residents (R2 and R3) half bed rails do not have doctor's orders on file.
-at 4:00 p.mident (R1) has doctor's order for Silodosine but facility does not have this medication. Per staff (S2), this medication has run out for 3 days. Dosage of Cranberry Extract in facility hand does not match the doctor's order on file.
-at 4:15 p.m., resident's (R2) has total of 6 medications and Vitamin supplements but no doctor's order on file.

The following updated/current documents were received on this day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)


....continued on 809C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
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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: GALICIA'S TULIP CARE HOME #2
FACILITY NUMBER: 011441162
VISIT DATE: 01/30/2024
NARRATIVE
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Page 3

Administrator to submit a copy of $3M Liability Insurance certificate by February 13, 2024.

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.

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: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 01/30/2024 07:21 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/30/2024 at 05:17 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: GALICIA'S TULIP CARE HOME #2
FACILITY NUMBER: 011441162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

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 for the following which pose immediate safety risks to presons in care: ointments and saline solution in residents' room; denture cleaners in residents' ensuite bathroom; Comet, Lysol and Mr. Clean cleaning agents and fabric disinfectant in the common bathroom cabinet.
POC Due Date: 01/31/2024
Plan of Correction
1
2
3
4
Staff locked the items.
Administrator to in-service the staff and submit training topic with attendees signatures by 1/31/24.
Type A
Section Cited
CCR
87465(h)(1)(C)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.

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 for unlocked medications which poses an immediate health, safety and/or personal rights risk to persons in care
POC Due Date: 02/01/2024
Plan of Correction
1
2
3
4
Staff locked the items.
Administrator to in-service the staff and submit training topic with attendees signatures by 1/31/24.
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: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 01/30/2024 07:21 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/30/2024 at 05:17 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: GALICIA'S TULIP CARE HOME #2
FACILITY NUMBER: 011441162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

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 for trash cans not having lids which poseva potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
1
2
3
4
Administrator to purchase trash bins with foot pedal operated lids and submit pictures 2/13/24.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

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 R4 not having Pre-admission Appraisal which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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2
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4
Administrator to complete the appraisal and submit self-certification by 2/13/24.
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: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 01/30/2024 07:21 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/30/2024 at 05:17 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: GALICIA'S TULIP CARE HOME #2
FACILITY NUMBER: 011441162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above for not conducting disaster drills as required which poses a potential safety and/or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
1
2
3
4
Administrator stated she'll have the drills conducted. Copy to be submitted by 2/13/24.
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
-This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and records review, the licensee did not comply with the section cited above for not having doctor's order for R2 and R3's half bed rails pose a potential safety and/or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
1
2
3
4
Administrator to obtain doctor's orders and submit copies by 2/13/24.
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: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 01/30/2024 07:21 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/30/2024 at 05:34 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: GALICIA'S TULIP CARE HOME #2
FACILITY NUMBER: 011441162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
87465 Incidental Medical and Dental Care
(e) 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 residents 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 record review, the licensee did not comply with the section cited above for no doctor's order for R2's medications and Vitamins which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
1
2
3
4
Administrator to obtain copy of doctor's order and submit copy by 1/31/24.
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above for facility not having Silodosine medication for R1 and dosage for 1 Cranberry fruit extract in facility's hand does not match the doctor's order which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
1
2
3
4
Administrator to obtain the Silodosine medication and doctor's order for Cranberry extract. Proof to be submitted by 1/31/24.
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: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 01/30/2024 07:21 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/30/2024 at 06:15 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: GALICIA'S TULIP CARE HOME #2
FACILITY NUMBER: 011441162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(a)
87555 General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 expired salad dressing which poses an immediate health and/or personal rights risk to persons in care
POC Due Date: 01/31/2024
Plan of Correction
1
2
3
4
Staff throw away the item.
Administrator to in-service the staff and submit proof by 1/31/24.
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: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 01/30/2024 07:21 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/30/2024 at 06:22 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: GALICIA'S TULIP CARE HOME #2
FACILITY NUMBER: 011441162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(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 record review, the licensee did not comply with the section cited above for R2 and R3's LIC602A Physician's Reports over a year old which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
1
2
3
4
Administrator stated she'll bring the residents to the doctor for medical appointments. Self-certification stating LIC602A are updated to be submitted by 2/13/24.
Type B
Section Cited
CCR
87463(c)

87463 Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

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 cited above in R2 andd R3's LIC625 over a year old which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
1
2
3
4
Administrator to update the LIC625 and submit self-certification by 2/13/24.
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: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 01/30/2024 07:21 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/30/2024 at 07:03 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: GALICIA'S TULIP CARE HOME #2
FACILITY NUMBER: 011441162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition....
-This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 staff not having LIC503 and TB test on file which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
1
2
3
4
Administrator to have the staff heatllt screened and TB tested and submit proof by 2/13/24.
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: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
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