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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601295
Report Date: 05/11/2022
Date Signed: 05/11/2022 07:12:02 PM

Document Has Been Signed on 05/11/2022 07:12 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:ESCUETA CARE HOME 3, INC.FACILITY NUMBER:
015601295
ADMINISTRATOR:ESCUETA, MILANETTEFACILITY TYPE:
740
ADDRESS:23571 RONALD LANETELEPHONE:
(510) 785-0203
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 4CENSUS: 4DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Soledad Escueta/Assistant AdministratorTIME COMPLETED:
07:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA was granted entry by staff, Ernesto Cochico. LPA met with Soledad Escueta, assistant administrator, and informed the purpose of visit. LPA also met with other staff, Joana Tiglao.

Facility has LIC808 Mitigation Plan on file.

LPA toured the facility inside out with Soledad Escueta. LPA inspected the living room, dining area, kitchen, bathrooms, bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, surgical masks and no touch temperature probe. Visitor's temperature and symptom checks are done at entry and recorded. Residents and staff are screened for COVID-19 symptoms and temperature checked daily and recorded. Supplies of PPEs checked and observed adequate for 30 days for staff. All trash bins were observed with foot operated pedal lids. Antigen test kits are readily available. COVID-19 signages were posted in prominent areas in the facility.

Fire extinguisher checked and observed fully charge with tag showed serviced March 31, 2022. First aid kit was observed complete with manual. Hot water temperature in one of the bathrooms tested and measured at 106.5 degrees Fahrenheit. Carbon monoxide and smoke detectors were operational.

At 5:03 pm, LPA observed staff's medications and supplements stored in unlocked closet close to the dining area.

.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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: ESCUETA CARE HOME 3, INC.
FACILITY NUMBER: 015601295
VISIT DATE: 05/11/2022
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Administrator to submit updated copies of the following documents by May 25, 2022:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan
4. Proof of $3M liability insurance

Deficiency is cited per Title 22 California Code of Regulations on LIC809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Soledad Escueta.

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

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/11/2022 07:12 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/11/2022 at 06:40 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: ESCUETA CARE HOME 3, INC.
FACILITY NUMBER: 015601295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309
87309 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
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Based on observation, the licensee did not comply with the section cited above. LPA observed staff's medications and supplements stored in unlocked closet which pose immediate heatth and safety risks to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Assistant administrator to in-service staff and submit copy with attendees signatures by 5/12/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
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