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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601313
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:51:51 PM

Document Has Been Signed on 04/21/2022 04:51 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:BEGONIA RESIDENTIAL CARE HOMEFACILITY NUMBER:
015601313
ADMINISTRATOR:BOLLOSO, JOVITAFACILITY TYPE:
740
ADDRESS:34814 BEGONIA STREETTELEPHONE:
(510) 429-7250
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Jovita Bolloso, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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On 4/21/2022 at 3:05PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Jovita Bolloso, Administrator explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hot water temperature in the shared clients’ bathroom was measured at 142.2 degree Fahrenheit. Fire extinguisher was last serviced on 4/1/2022.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 4/28/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC9099C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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: BEGONIA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601313
VISIT DATE: 04/21/2022
NARRATIVE
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Continued from LIC9099.

-LIC610E Emergency Disaster Plan
-An updated copy of Administrator certificate

The following deficiencies were observed:

-At 3:15PM, LPA observed Staff 2 (S2) was not associated to the facility.
-At 3;20PM, LPA observed unlocked drawer near stove in kitchen containing knives.
-At 3:25PM, LPA observed hot water in shared bathroom measure at 142.2 degrees F.
-At 3:33PM, LPA observed unlocked staff room that contained scissors, vitamins, and Gain detergent pods accessible.

An immediate civil penalty of $100 was assessed.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2022 04:51 PM - It Cannot Be Edited


Created By: Laura Hall On 04/21/2022 at 04:11 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: BEGONIA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(2)
87303 Maintenance and Operation (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

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 hot water measuring at 142.2 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Administrator agreed to adjust temperature between 105 - 120 and submit photo of temperature to CCLD by POC date.
Type A
Section Cited
CCR
87411(g)(1)
87411 Personnel Requirements- General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or

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 having S2 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Administrator agreed to submit LIC9182 and a of S2's photo ID to CCLD in order to associate to facility by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2022 04:51 PM - It Cannot Be Edited


Created By: Laura Hall On 04/21/2022 at 04:22 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: BEGONIA RESIDENTIAL CARE HOME
FACILITY NUMBER: 015601313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
87303 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.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 having knives, scissors, vitamins and detergent accessible which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2022
Plan of Correction
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Administrator agreed to place knives in a locked cabinet to make inaccessible, and to change the door knob leading to staff room with one that locks to make scissors, vitamins and detergent inaccessible and submit photo to CCLD by POC date.
Knives were put away in locked box in garage during visit.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


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