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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200694
Report Date: 02/20/2023
Date Signed: 02/20/2023 01:39:12 PM

Document Has Been Signed on 02/20/2023 01:39 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:H & M HOMES STANDISHFACILITY NUMBER:
019200694
ADMINISTRATOR:OLIVE LOPEZFACILITY TYPE:
740
ADDRESS:18543 STANDISH AVENUETELEPHONE:
(510) 276-2240
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
02/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:John Louie Neri/StaffTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, John Louie Neri, and informed the purpose of visit. Olive 'Lynn' Lopez Neri. administrator, arrived after about 45 minutes.

Facility has an approved LIC808 Mitigation Plan. Facility has LIC9282 Infection Control Plan on file which LPA obtained copy on this day, February 20, 2023.

LPA toured the facility inside out with John Louie Neri. LPA inspected the living room, dining room, kitchen, hallways, residents bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked. Facility has antigen test kits readily available. COVID-19 signages were observed throughout the facility. Bathroom lavatories were observed with liquid soap.

Fire extinguisher checked, and observed fully charge with tag showed serviced June 10, 2022. Hot water temperature in the common bathroom was tested and measured at 114 degrees Fahrenheit.

.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2023
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: H & M HOMES STANDISH
FACILITY NUMBER: 019200694
VISIT DATE: 02/20/2023
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LPA observed the following:
1. Trash cans with no lids in residents shared bedroom and ensuite bathroom.
2. Cleaning supplies, tools, pails of paint in two unlocked storages.
3. Scissors in drawer without lock in the dining room.
4. Medications in unlocked staff bedroom.
5. Common towels and hand hand towels in two bathrooms.

Adminstrator to submit the following by March 6, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. Proof of $3M liability insurance.
5. Current N95 fit testing records/certificates

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, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with administrator.

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: 02/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/20/2023 01:39 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/20/2023 at 12:51 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: H & M HOMES STANDISH
FACILITY NUMBER: 019200694

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)(C)
87465 Incidental Medical and Dental Care
(h)(1)(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. LPA observed medications in unlocked staff room which poses an immediate safety risk to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
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Staff locked the room immediately.
In addition, administrator to in-service the staff and submit training topic with attendees signatures by 2/21/23.
Type A
Section Cited
CCR
87309(a)
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.


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. LPA observed the following: unlocked storages; scissors in drawer without lock which pose immediate safety risks to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
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Staff locked the scissors and storage immediately.
In addition, administrator to in-service the staff and submit training topic with attendees signatures by 2/21/23.
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: 02/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/20/2023 01:39 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/20/2023 at 01:26 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: H & M HOMES STANDISH
FACILITY NUMBER: 019200694

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
87307 Personal Accommodations and Services
(a) Living accommodations and grounds..... The following provisions shall apply:
(3)(C) The use of common wash cloths and towels shall be prohibited.


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 2 out of 2 bathrooms with common towels and hand towels which pose poptential health, safety and personal rights risks to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
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Admnistrator removed the towels and hand towels.
In addition, administrator to have paper towel holder installed, and provise paper towel for hand drying and ensure each resident is provided towel. Pictures to be submitted by 3/06/23.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2023


LIC809 (FAS) - (06/04)
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