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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200694
Report Date: 08/17/2023
Date Signed: 08/17/2023 02:02:44 PM

Document Has Been Signed on 08/17/2023 02:02 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:
08/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maria Roy/Licensee and
Olive 'Lynn' Lopez/Administrator		TIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to missing residents reported and Special Incident Reports (SIRs) for residents (R1 and R2) submitted by the administrator. LPA met with Maria Roy, licensee, and Olive 'Lynn' Lopez, administrator, and informed the reason for visit.

LPA obtained and reviewed R1 and R2's LIC602A Physician's Report, Appraisal and Individual Program Plan (IPP).

SIRs indicated the following:
1. Resident (R1)
SIR dated 8/11/23 with incident date 8/09/23 - facility received a call from Emergency Department around 4:00 pm. Staff spoke with the doctor, and was told that R1 has an open wound on his finger and bruise on the cheek. R1 was found lying on the front of a building in Hayward. R1 was confused and not able to discuss what happened. A good samaritan brought R1 to the hospital.
2. Resident (R2)
SIR dated 8/16/23 with incident date 8/16/23 - R2 was last seen on 8/16/23 between 6:00 am and 6:30 am by R2's roommate leaving their room. Staff searched for R2 around the facility and surrounding neighborhood, and called 9-1-1.

On this day, August 17, 2023, LPA obtained copies R1's Hospital Visit Information, R1 and R2's LIC601 Identification and Emergency Contact Information. LPA conducted inspection and interviews.

Administrator stated R1 sustained injury on the finger which was stapled and bruise on the cheek. Review of Hospital Visit Information confirmed administrator's statement. R2 is still missing.

........continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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: 08/17/2023
NARRATIVE
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Review of R1's LIC602A revealed R1 has dementia and can not leave the facility unassisted. R2's LIC602A indicated R2 can not leave the facility unassisted, and IPP revealed R2 has history of AWOL behavior.

During today's visit, LPA observed all entrance/exit doors without auditory signals.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed on this day for deficiency H&S 1569.312(a), and will continue for $100.00 per day until corrected.

Deficiencies and plan and proof of correction and civil penalty were discussed with licensee and administrator.

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: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/17/2023 02:02 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/17/2023 at 01:16 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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
HSC
1569,312(a)

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ยง1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2.
-This requirement is not met as evidenced by:
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Administrator to do the following and submit proof by 8/18/23:
1. Re-assess residents and provide the care needs immediately.
2. In-service staff.
3. Schedule an Interdisciplinary Meeting with Regional Center of East Bay and Behaviorist.
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-Based on interview and review of records, the licensee did not comply with the section above for R1 and R2 who were able to AWOL which posed immediate risk to persons in care.
Civil penalty assessed due to R1 sustaining injuries.
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$500,00 civil penalty is assessed on this day.
Type A
08/18/2023
Section Cited
CCR87705(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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Corrected.
Administrator had the staff purchased and installed auditory signals while LPA is still at the facility.
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-Based of observation, the licensee did not comply with the section above, for entrance and exit doors not having auditory signals which posed immediate 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: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
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