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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601483
Report Date: 08/13/2025
Date Signed: 08/13/2025 08:03:24 PM

Document Has Been Signed on 08/13/2025 08:03 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:ST. LOURDES HOMEFACILITY NUMBER:
015601483
ADMINISTRATOR/
DIRECTOR:		BALINTONA, JUSTINOFACILITY TYPE:
740
ADDRESS:1626 ASHBURY LANETELEPHONE:
(510) 265-0818
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 6DATE:
08/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Justino Balintona/Licensee-AdministratorTIME VISIT/
INSPECTION COMPLETED:
08:05 PM
NARRATIVE
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On this day, August 13, 2025, at 12:40 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Warlita Romero and Norma Gano. LPA called and spoke over the phone with Justino Balintona, licensee-administrator, and informed the reason for visit. LPA asked, and licensee-administrator authorized Norma Gano to be with LPA during inspection. Licensee-administrator arrived around 1:15 pm.

LPA started inspection with Norma Gano and continued with licensee-administrator. LPA inspected the dining room, kitchen, bedrooms, bathrooms, living room, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked.

Facility has smoke and carbon monoxide detectors that were tested and observed in operating condition. Hot water temperature in the common bathroom was tested, and measured at 111.6 degrees Fahrenheit. Facility conducts drills and record showed last conducted July 12, 2025. Fire extinguisher checked and receipt showed purchased May 20, 2025.

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


...continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2025
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 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 8
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: ST. LOURDES HOME
FACILITY NUMBER: 015601483
VISIT DATE: 08/13/2025
NARRATIVE
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LPA observed the following:
-at 12:55 pm, medications in kitchen drawer without lock.
-at 1:10 pm, Ca-Rezz incontinent wash, Hydrocortisone cream, lighter in unlocked closet in the hallway.
-at 1:15 pm, Ca-Rezz in the common bathroom.
-at 1:20 pm, unlocked scissors in the resident's room.
-at 1:22 pm, Hydrocortisone cream, Ca-Rezz incontinent wash and shaving cream in another resident's room.
-at 1:31 pm, scissors, mallet, hammer, screw drivers, lubricant in a plastic storage container in the backyard.
-at 3:00 pm, staff (S2) does not have postural support training for 2024.
-at 3:15 pm, staff (S3) who was hired in 2024 has only 16 hours of the total 40 hours required training.
-at 3:20 pm, staff (S4) does not have postural support training for 2024.
-at 3:32 pm, staff (S5) has not completed the required 40 hours of training within the required first 2 weeks of employment.
-at 4:15 pm, resident (R2) has multi Vitamins and Ferrous sulfate administered but these are not included on the medications/supplements listed on LIC602A dated 5/27/25.
-at 4:50 pm, resident (R3) has 1 medication on listed in After Visit Summary dated 8/05/25 but facility does not have the medication.
-at 5:35 pm, resident's (R4) two prescribed medications filled on 6/18/25 and one filled on 7/18/25 not listed on LIC622 Centrally Stored Medication and Destruction Record. Facility does not have 3 of the prescribed medications. Tylenol (Acetaminophen) order is 325 mg but the one in facility's hand is 500 mg.

LPA obtained copies of the following updated/current documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan
4. $3M liability insurance certificate



.......continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 08/13/2025 08:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/13/2025 at 06:42 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: ST. LOURDES HOME
FACILITY NUMBER: 015601483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 the following which pose an immediate health, safety andor personal rights risks to persons in care: Ca-Rezz incontinent wash, Hydrocortisone cream, lighter in unlocked closet in the hallway; scissors, mallet, hammer. screw drivers, lubricant in a plastic storage container in the backyard; Ca-Rezz in common bathroom; scissors in one of the residents' rooms. A $250.00 civil penalty is assessed.
POC Due Date: 08/14/2025
Plan of Correction
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Staff locked the items.
In addition, administrator to in-service the staff and submit proof by 8/14/25.
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 in medications in kitchen drawer without lock which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
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Staff locked the medications.
In addition, administrator to in-service the staff and submit proof by 8/14/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 08/13/2025 08:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/13/2025 at 06:42 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: ST. LOURDES HOME
FACILITY NUMBER: 015601483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above in the following which pose immediate health and/or personal rights risks to persons in care: R3 has 1 medication on listed on After Visit Summary dated 8/05/25 but facility does not have medication; facility does not have 3 of R4's prescribed medications; R4's doctor's order for Tylenol (Acetaminophen) order is 325 mg but the one in facility's hand is 500 mg
POC Due Date: 08/14/2025
Plan of Correction
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Administrator to do the following and submit proof by 8/14/25.
1. Check with the doctor if the medications are no longer needed and obtain discontinued orders; otherwise, obtain the medications.
2. Obtain correct dosage for Tylenol.
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(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 resident'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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Based on observation and record review, the licensee did not comply with the section cited above in administering multi Vitamins and Ferrous sulfate to R2 but these are not included on the medications/supplements listed on LIC602A dated 5/27/25 which pose an immediate health and/or personal rights risk to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
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Administrator to check with the doctor if the medication/supplements are needed by R2. If so, obtain doctor's order. Otherwise, stop the administration. Proof to be submitted by 8/14/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 08/13/2025 08:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/13/2025 at 06:42 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: ST. LOURDES HOME
FACILITY NUMBER: 015601483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in staff, S2 and S4, not having required postural support training for 2024 which posed a potential safety and/or personal rights risks to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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Administrator to have the staff trained and submit proof by 8/27/25.
Type B
Section Cited
HSC
1569.625(b)(1)
1569.625 Staff training; legislative findings; contents
(b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in S3 & S5 not having the complete required 40 hours of training which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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Administrator to have the staff complete the training. Proof to be submitted by 8/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 08/13/2025 08:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/13/2025 at 07:20 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: ST. LOURDES HOME
FACILITY NUMBER: 015601483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 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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2
3
4
Based on record review, the licensee did not comply with the section cited above in R4's two prescribed medications filled on 6/18/25 & one filled on 7/18/25 not listed on LIC622 Centrally Stored Medication and Destruction Record which pose a potential personal rights risk to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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2
3
4
Administrator to record the medications and submit copy of the LIC622 by 8/27/25.
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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
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: ST. LOURDES HOME
FACILITY NUMBER: 015601483
VISIT DATE: 08/13/2025
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for repeat violation of section 87309(a) within 12 month period and will continue for $100.00/day if not corrected. Failure to submit proof of corrections for the other deficiencies may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the licensee-administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, LIC421FC Civil Penalty Assessments, and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC809 (FAS) - (06/04)
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