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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601347
Report Date: 12/03/2024
Date Signed: 12/03/2024 11:34:21 AM

Document Has Been Signed on 12/03/2024 11:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:C & L HOME FOR THE ELDERLYFACILITY NUMBER:
015601347
ADMINISTRATOR/
DIRECTOR:		GUZMAN, JOSELITO A.FACILITY TYPE:
740
ADDRESS:2660 HOP RANCH ROADTELEPHONE:
(510) 731-7743
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
12/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Vincent Catequista, Care Staff TIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
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On 12/03/2024 at 9:20 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Continuation Inspection. LPAs met with Care Staff, Vincent Catequista, and explained the purpose of the visit. Care Staff phoned the Administrator who gave authorization through the phone to have staff sign.

LPAs toured facility with Vincent Catequista including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 93 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was purchased on 11/12/2024. First aid kit was observed to be complete. LPAs reviewed 4 residents records. LPAs reviewed 4 staff records. LPAs reviewed a sample of resident’s medications.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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Document Has Been Signed on 12/03/2024 11:34 AM - It Cannot Be Edited


Created By: Patricia Manalo On 12/03/2024 at 10:02 AM
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: C & L HOME FOR THE ELDERLY
FACILITY NUMBER: 015601347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 degrees C) and not more than 120 degree F (49 degrees 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 having the water temperature is measured at 98.3 degrees Fahrenheit which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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By POC due date, Administrator agreed to correct hot water temperature and submit proof of correction to CCLD.
Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 by not having documentations for R1, R2, R3, R4 which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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By POC date, Administrator agrees to obtain the following documents for R1, R2, R3, and R4: Consent Form, Safeguards for Property/ Valuables, Medical Assessment, TB test, Appraisal Needs and Services, LIC613C, and ID and Emergency Information
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 12/03/2024 11:34 AM - It Cannot Be Edited


Created By: Patricia Manalo On 12/03/2024 at 10:02 AM
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: C & L HOME FOR THE ELDERLY
FACILITY NUMBER: 015601347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 and cleaning chemicals found unlocked and accessible to residents in the kitchen. Medication and paint was observed to be unlocked and accessible to residents in the bathroom which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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Administrator agree to self certify that they read and understand the regulation and submit self-certification to CCLD by POC due date. Staff locked the items during the 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 12/03/2024 11:34 AM - It Cannot Be Edited


Created By: Patricia Manalo On 12/03/2024 at 10:02 AM
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: C & L HOME FOR THE ELDERLY
FACILITY NUMBER: 015601347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

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 having a Liability Insurance that expired on 2020 in file which poses a potential health and safety risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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Administrator showed proof of liability insurance on today's visit. Deficiency cleared.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

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 cluttered such as bed spring, bed frame, bikes, cardboard, headboard, crates, and etc. in the side backyard which poses a potential health and safety risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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By POC date, Administrator agrees to remove the items such as bed spring, bed frame, bikes, cardboard, headboard, crates, and etc. and send proof to CCLD 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 12/03/2024 11:34 AM - It Cannot Be Edited


Created By: Patricia Manalo On 12/03/2024 at 10:02 AM
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: C & L HOME FOR THE ELDERLY
FACILITY NUMBER: 015601347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 by having an expired CPR certificate for S4 which poses a potential health and safety risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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By POC date, the Administrator agrees to obtain a new CPR certificate for S4 and send proof to CCLD.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 food that is not properly stored and expired canned goods found in the cabinet which poses a potential health and safety risk to persons in care.
POC Due Date: 12/05/2024
Plan of Correction
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Administrator removed expired canned goods and properly labeled and stored food during the visit. Deficiency cleared during the visit.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 12/03/2024 11:34 AM - It Cannot Be Edited


Created By: Patricia Manalo On 12/03/2024 at 10:02 AM
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: C & L HOME FOR THE ELDERLY
FACILITY NUMBER: 015601347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having half bed rail with no doctor's order for R4 in Room #2 which poses a potential health and safety risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Administrator agrees to obtain a doctor's order for the half bed rail for R4 and send proof of document to CCLD by POC date.
Type B
Section Cited
CCR
87412(a)
87412(a) Personnel Records
(a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:


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 by not having the Administrator records in the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator agrees to obtain their file that includes LIC 501, LIC 503, TB test, Administrator Certificate, First Aid Certificate, etc. and send to CCLD 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: C & L HOME FOR THE ELDERLY
FACILITY NUMBER: 015601347
VISIT DATE: 12/03/2024
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/11/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 10:00 AM, LPAs observed that R1, R2, R3, and R4 did not have all the documents in the file.

At 10:30 AM LPAs observed that S4 does not have a CPR Certificate on file.

At 10:50 AM, LPAs observed that the water temperature is measured at 98.3 degrees Fahrenheit at the shared bathroom.

At 10:35 AM, LPAs observed knives and cleaning chemicals found unlocked and accessible to residents in the kitchen.

At 11:05 AM, LPAs observed medication and paint found unlocked and accessible to residents in the bathroom.

At 11:00 AM LPAs observed items such as bed spring, bed frame, bikes, cardboard, headboard, crates, and etc., in the side backyard.

Continue to LIC 809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: C & L HOME FOR THE ELDERLY
FACILITY NUMBER: 015601347
VISIT DATE: 12/03/2024
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At 11:30, LPAs observed in Room #2 having half bed rail with no doctor's order for R4.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Care Staff. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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