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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201086
Report Date: 02/09/2024
Date Signed: 02/09/2024 03:24:37 PM

Document Has Been Signed on 02/09/2024 03:24 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:K & J RESIDENTIAL CARE HOME-HAYWARDFACILITY NUMBER:
019201086
ADMINISTRATOR:BROWN, ELTONFACILITY TYPE:
740
ADDRESS:838 W. SUNSET BLVD.TELEPHONE:
(510) 363-9387
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 5CENSUS: 5DATE:
02/09/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Elton Brown/Administrator TIME COMPLETED:
03:25 PM
NARRATIVE
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At 10:40 am on this day, February 9, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on January 15, 2024. LPA was granted entry by Ester Ramirez, care staff. LPA met with Elton Brown, administrator, and informed the reason for visit.

LPA reviewed 5 resident records and interview 2 residents. LPA inspected the medications. compared with doctor's order on file and LIC622 Centrally Stored Medication and Destruction Records and Medication Administration Record (MAR).

LPA observed the following:
-at 11:10 a.m. to 11:20 a.m., residents (R1 and R2) LIC602A Physician's Reports were over a year old.
-at 11:30 a.m., residents (R1 and R5) half bed rails have no doctor's order on file.
-at 11:40 a.m. R1's LIC625 Appraisal/Needs and Service Plan is over a year old.
-at 11:55 a.m., resident (R5) LIC9172 Functional Capability Assessment has contradicting information on eating and repositioning.
-at 12:10 p.m,, R1 has 15 medications listed on the doctor's order on file; however, R1 has only 7 medications on facility's hand, one of which not on the order.
-at 12:30 p.m., most current order of medications for R2 does not have dosage; Baclofen dosage from
April 11, 2023 order is not consistent with what the facility has on hand. One medication on the current list but facility does not have the medication
-at 1:15 p.m., R3's medications order on file for 17 meds but facility only has 11 on hand. Order for Vit D3 is 50 mcg 1 tablet per day, and on facility's hand is 25 mcg and facility administers only 1 tablet per day.

....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: K & J RESIDENTIAL CARE HOME-HAYWARD
FACILITY NUMBER: 019201086
VISIT DATE: 02/09/2024
NARRATIVE
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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 the administrator. Administrator has to leave the facility, and authorized Ester Ramirez to sign and receive this report.

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: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/09/2024 03:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/09/2024 at 02:11 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: K & J RESIDENTIAL CARE HOME-HAYWARD
FACILITY NUMBER: 019201086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on reord review, the licensee did not comply with the section cited above in R2's doctor's order for some of the mediations not having dosage and dosage of 1 medication not longer consistent with what the facility has on hand which pose an immediate health risks to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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Administrator to obtain complete updated order and sbumit copy by 2/10/24.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for the following: R1 has 15 medications on the doctor's order on file; however, R1 has only 7 medications on facility's hand, of which 1 is not on the order; R3's medications order on file for 17 meds but facility only has 11 on hand; facility administer's R3's Vit D3 less than th dosage prescribed. These pose an immediate health risks to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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Administrator to do the following and submit proof by 2/10/24:
1.Obtain doctor's order or discontinued order.
2. Administer the correct dosage for Vit D3 to R3.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/09/2024 03:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/09/2024 at 02:11 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: K & J RESIDENTIAL CARE HOME-HAYWARD
FACILITY NUMBER: 019201086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R1's LIC625 Appraisal/Needs and Service Plan over a year old.which poses a potential health risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Administrator to update the LIC625 and submit copy by 2/23/24..
Type B
Section Cited
CCR
87458(c)
87458 Medical Assessment
(c) The licensee shall obtain an updated medical assessment when required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in
R1 and R2’s LIC602A Physician Report over a year old which pose a potential health risks to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Administrator to obtain updated LIC602As. Self-certification to be submiitted by 2/23/24.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


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Document Has Been Signed on 02/09/2024 03:24 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/09/2024 at 02:31 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: K & J RESIDENTIAL CARE HOME-HAYWARD
FACILITY NUMBER: 019201086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
-This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in R1 and R5's bed rails not having doctor's order on file which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Administrator stated he'll obtain doctor's orders. Copies to be submitted by 2/23/24.
Type B
Section Cited
CCR
87459(a)
87459 Functional Capabilities
(a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living......

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R5’s LIC9172 having contradicting information on eating and reposition which poses a potential personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Administrator to update the LIC9172 and submit by 2/23/24.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


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