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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200750
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:21:27 PM

Document Has Been Signed on 01/29/2025 04:21 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:SCOTT VILLAFACILITY NUMBER:
019200750
ADMINISTRATOR/
DIRECTOR:		JONABELLE TOLENTINOFACILITY TYPE:
740
ADDRESS:1560 MIDDLE LANETELEPHONE:
(510) 782-7833
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 35CENSUS: 34DATE:
01/29/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Lulin 'Lucy' Wu/Back-up AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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On this day, January 29, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 2 complaint (Complaint #15-AS-20250127122838). LPA met with Lulin 'Lucy' Wu, back-up administrator (BUA), and informed the reason for visit.

LPA obtained copies of LIC9020 Register of Facility Residents. When verified for total number of residents on LIC9020, BUA stated resident (R1) passed away on 1/15/25 in the hospital; however, review of documents and LPA's efaxed folder for the facility revealed no Death Report submitted. LPA also observed Unusual Incident Reports and SOC341 on resident's (R2) file but these documents were not submitted nor received by the Department. Facility did not report to the Department within 2 hours upon knowledge of the suspected abuse.

LPA toured the facility inside out with the BUA. LPA inspected the common areas, activity room, dining room, kitchen, ensuite toilets, shower room. LPA randomly selected 6 residents rooms for inspection.

LPA observed the following:
-at 2:19 pm to 2:21 pm, auditory signal on the exit door in one of the resident's rooms not in working condition. LPA also observed extra hospital bed sideways against the wall and detached baseboard and wall moulding with protruding nail in this room.


.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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Document Has Been Signed on 01/29/2025 04:21 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/29/2025 at 02:35 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: SCOTT VILLA
FACILITY NUMBER: 019200750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2025
Section Cited
CCR
87705(d)

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87705 Care of Persons with Dementia
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates .........
-This requirement is not met as evidenced by:
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Corrected.
Auditory signal fixed while LPA is at the facility.
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-Based on observation, the licensee did not comply with the section above in auditory signal not in working conditon which poses an immediate safety risk to persons in care.
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Type A
01/30/2025
Section Cited
CCR87211(b)

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87211Reporting Requirements (b) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours.......
-This requirement is not met as evidenced by:
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BAU and licensee to read the Regulations, do the following, and submit POC by 1/30/25:
1. Ensure that reporting is done within the required time frame.
2. Submit self-certification.
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-Based on records review and interview, the licensee did not comply with the section in not reporting to the agencies includin the Department the suspected abuse which posed an immediate 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: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2025 04:21 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/29/2025 at 02:43 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: SCOTT VILLA
FACILITY NUMBER: 019200750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2025
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Corrected.
The following were done while LPA was at the facility:
1. Moulding and baseboard fixed/repaired.
2. Extra hospital bed was removed from the resident's room and disposed.
The extra hospital bed was removed from the resident's room.





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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above in extra hospital bed, detached baseboard and wall moulding with protruding nail in the resident's room which pose a potential risks to persons in care. This is a repeat violation.
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A $250.00 civil penalty is assessed.
Type B
02/12/2025
Section Cited
CCR87211(a)(1)(A)

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87211 Reporting Requirements
(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified (A)Death of any resident from any cause regardless of where the death occurred....
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Corrected.
BUA submitted the Death Report to LPA while LPA was at the facility.
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-This requirement is not met as evidenced by:
-Based on record review and interview, the licensee did not comply with the section above in not sending the Death Report for resident (R1) which posed a potential personal rights risk 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: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


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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: SCOTT VILLA
FACILITY NUMBER: 019200750
VISIT DATE: 01/29/2025
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 87303(a) within 12 month period. Failure to submit proof of correction by plan of correction due date, may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with the BUA.

Exit interview conducted. Appeal Rights, LIC421FC 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: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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