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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 09/29/2022
Date Signed: 09/29/2022 05:56:53 PM

Document Has Been Signed on 09/29/2022 05:56 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:COLONIAL ACRES RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200664
ADMINISTRATOR:SARAH MAY BALINGITFACILITY TYPE:
740
ADDRESS:18905 STANDISH AVENUETELEPHONE:
(510) 276-0939
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 20CENSUS: 13DATE:
09/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:John Ronald Olivarez/LicenseeTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced health & safety inspection as a result of the Department receiving a complaint (15-AS-20220927100258). LPA met with John Ronald Olivarez, licensee, and Celeste Olivarez, facility consultant,

LPA toured facility with Celeste Olivarez. LPA inspected the kitchen, dining area, residents bedrooms, staff room, bathrooms, hallway. tv room. There's sufficient food supplies good for 7 days of non-perishable and 2 days of perishables. Facility has running water and electricity.

LPA observed the following:
1. Entrance door's auditory signal was disabled. Review of resident (R1) records and interview of staff revealed R1 has wandering and sundowning behavior.
2. Oxygen concentrator in one of the resident's bedroom. LPA reviewed records and interviewed and R2 who indicated he uses the oxygen. There's no "No smoking. Oxygen in Use" posters posted by the entrance and exit doors and resident's bedroom door,
3. Resident's medications unlocked in the refrigerator, and knives and cleaning supplies in drawers without lock in unlocked kitchen.
4. Unlocked utility room where cleaning supplies are kept.

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 may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with facility consultant.

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: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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 3
Document Has Been Signed on 09/29/2022 05:56 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/29/2022 at 04:10 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: COLONIAL ACRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2022
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Staff locked the kitchen.
Licensee to do the following and submit proof by 09/30/2022.
1. Install locks on the kitchen drawers where cleaning supplies and knives are kept.
2. Purchase a lockbox for medications that need refrigeration,
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above for having unlocked medications, knives and cleaning supplies in unlocked kitchen which pose immediate safety risks to persons in care.
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3. In-service staff
Type A
09/30/2022
Section Cited
CCR87309(a)

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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.

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Staff locked the room.
In addition, licensee to in-service the staff and submit copy of in-service training with attendees signatures by 09/30/2022.
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-This requirement is not met as evidenced by:

-Based on observation, the licensee did not comply with the section above for the unlocked utility room which poses immediate safety risk to persons in care.
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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: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/29/2022 05:56 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/29/2022 at 04:40 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: COLONIAL ACRES RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2022
Section Cited
CCR
87705(j)

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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

-This requirement is not met as evidenced by:
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Staff turned-on the auditory signal.
Licensee to in-service the staff and submit copy of in-service training with attendees signatures by 09/30/2022.
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-Based on observation, the licensee did not comply with the section above for having the auditory signal on the entrance door disabled which poses immediate safety risk to persons in care.
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Type B
10/13/2022
Section Cited
CCR87618(b)(3)(B)

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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following:(3) Ensuring that the use of oxygen equipment meets the following requirements:(B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.
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Licensee to post posters and submit pictures by 10/13/2022.
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-This requirement is not met as evidenced by:

-Based on observation, records review and interview, the licensee did not comply with the section above for not having the poster posted which poses potential safety risk to persons in care.
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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: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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