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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 12/20/2024
Date Signed: 12/20/2024 06:47:38 PM

Document Has Been Signed on 12/20/2024 06:47 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/
DIRECTOR:		MAGALLONES, ADELIZA RFACILITY TYPE:
740
ADDRESS:18905 STANDISH AVENUETELEPHONE:
(510) 276-0939
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 20CENSUS: 13DATE:
12/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:10 PM
MET WITH:Mary Eileen Legados/Administrator
and John Ronald Olivarez/Licensee		TIME VISIT/
INSPECTION COMPLETED:
06:50 PM
NARRATIVE
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On this day, 12/20/24, at 4:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management resulting from the investigation of a complaint (15-AS-20220927100258) by the Department. LPA met with Mary Eileen Legados, administrator (ADM), and informed the purpose of visit. John Ronald Olivarez, licensee, arrived after about an hour.

During investigation, the Department observed the following:
1. Resident's (R1) LIC602A Physician's Report dated 1/25/22 indicated the following: non-ambulatory and bedridden; contractures on lower & upper extremities; advanced frontotemporal dementia; fractured pelvis (unable to rehabilitate). The staff interviewed indicated R1 needs to be repositioned. LIC9020 Register of Facility Clients/Resident was bedridden.
2. LIC602A showed R1 was dependent on others with all activities of daily living (ADLs).
3. R1's LIC9172 Functional Capability Assessment was incompletely filled-up.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil is assessed for deficiency section # 87202(a)(2) and will continue for $100.00/day until corrected.

Deficiencies, plan and proof of corrections and civil penalty were discussed with licensee and ADM.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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 12/20/2024 06:47 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/20/2024 at 05:29 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: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2024
Section Cited
CCR
87202(a)(2)

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87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by...... Prior to accepting or retaining any of the following types of persons.... licensee shall .... obtain an appropriate fire clearance approved by city, county, tor district.....
....(2) Bedridden persons.
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R1 is no longer at the facility.

Administrator to review all residents files and check their ambulatory status. Proof to be submitted by 12/21/24.
A $500.00 civil penalty is assessed.
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-This requirement is not met as evidenced by:
-Based on record review and interviews, the licensee did not comply with the section above when R1 who is bedridden was admitted and facility does not have bedridden fire clearance.
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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: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/20/2024 06:47 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/20/2024 at 05:39 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: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2025
Section Cited
CCR
87615(a)(5)

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87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(5) Residents who depend on others to perform all....
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Licensee and administrator to read the Regulations and ensure no resident with prohibited health conditions is admitted to the facility. Self-certification to be submitted by 1/03/25.
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... activities of daily living for them....
-This requirement is not met as evidenced by:
-Based on record review and interviews, the licensee did not comply with the section above when R1 who is dependent on others will all ADLs was admitted which posed a potential health risks to person in care.
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Type B
01/03/2025
Section Cited
CCR87506(a)

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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:
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Administrator to review all residents files and complete the records. Self-certification to be submitted by 1/03/24.
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-Based on records review, the licensee did not comply with the section in R1's incomplete LIC9172 which posed a potential health, safety and/or personal rights risks to person 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: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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