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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201168
Report Date: 08/20/2024
Date Signed: 08/20/2024 09:09:35 PM

Document Has Been Signed on 08/20/2024 09:09 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:GENUINE LOVE CARE HOMEFACILITY NUMBER:
019201168
ADMINISTRATOR/
DIRECTOR:		DIMAGULA,HAROLD & EMELITAFACILITY TYPE:
740
ADDRESS:22947 FULLER AVE.TELEPHONE:
(510) 274-5207
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 5CENSUS: 1DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Emelita Dimaguila/AdministratorTIME VISIT/
INSPECTION COMPLETED:
09:15 PM
NARRATIVE
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On this day, August 20, 2023, at 2:00 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by Harold Dimaguila, staff. LPA met with Emelita Dimaguila, administrator, and informed the reason for visit.

Facility has Infection Control Plan that was submitted on August 2, 2022.

LPA toured the facility inside out with the administrator. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables.

Fire extinguisher purchased on was observed fully charge and purchased on Carbon monoxide and smoke detectors were tested and observed in operating condition. Hot water temperature in the common bathroom was tested and measured at 118.5 degrees Fahrenheit.

LPA reviewed 5 staff and 1 residents files, and interviewed 1 resident. Facility does not handle residents' cash resources. Medications checked, and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Records.

LPA observed the following:
-at 2:05 pm, staff who stated she's been at the facility since Sunday, 8/18/24, is not fingerprinted.
-at 2:12 pm, scissors and Vicks vaporub in the table in the living room.
-at 2:14 pm, peeler, grater in kitchen drawer without lock.
-at 2:15 pm, staff's medications in another kitchen drawer without lock.

......continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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: GENUINE LOVE CARE HOME
FACILITY NUMBER: 019201168
VISIT DATE: 08/20/2024
NARRATIVE
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Page 2

-at 2:19 pm, resident's medications in the refrigerator in the kitchen.
-ar 2:25 pm, disinfectant spray and Polident denture cleaner in bathroom cabinet without lock.
-from 2:32 to 2:34 pm, missing baseboard and water stained baseboards and siding in one of the residents' room. Mildew in the common bathroom.
-at 2:40 pm, resident R1's bed has half bed rails but no doctor's order on file
-at 3:00 pm, facility does not have telephone service and does not conduct disaster drill.
-at 4:00 to 4:30 pm staff (S3, S4 and S5) do not have First Aid certificate and no 40 hours required training, 10 hours on the job training and medication training on file. S5 does not have LIC501 Personnel record. S4 and S5 do not have LIC503 Health Screening record on file.
-at 6:30 pm, resident (R1) has doctor's order for 3 medications but the facility does have them.

Administrator to submitted the following updated/current documents on this day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $300.00 civil penalty is assessed for deficiency section 87355(e)(1) for staff who is not fingerprinted, and will continue for $100.00/day until corrected. Failure to submit proof of corrections by plan of correction due dates for other deficiencies may result in additional civil penalties.

Deficiencies, plan and proof of corrections, and civil penalty were discussed with the administrator,

Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 08/20/2024 09:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2024 at 07:19 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: GENUINE LOVE CARE HOME
FACILITY NUMBER: 019201168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risk to persons in care: scissors and Vicks vaporub in the table in the living room; peeler, grater and staff's medications in kitchen drawers without lock; disinfectant spray and Polident denture cleaner in bathroom cabinet without lock.
POC Due Date: 08/21/2024
Plan of Correction
1
2
3
4
Administrator locked all the items.
In addition, administrator to in-service the staff and submit copy of training topics with attendees signatures by 8/21/24.
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in S5 not fingerprinted which poses an immediate safety and/or personal rights risks to person in care.
POC Due Date: 08/21/2024
Plan of Correction
1
2
3
4
Staff went to fingerprinting while LPA was at the facility.
Administrator not to have the staff work until fingerprint cleared and associated and submit self-certification.
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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 08/20/2024 09:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2024 at 07:19 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: GENUINE LOVE CARE HOME
FACILITY NUMBER: 019201168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to person in care: missing baseboard and water stained baseboards and siding in one of the residents' room; mildew in the common bathroom.
POC Due Date: 09/03/2024
Plan of Correction
1
2
3
4
Administrator to have the baseboard and siding fixed and clean the bathroom. Pictures to be submitted by 9/03/24
Type B
Section Cited
CCR
87311
Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in not having telephone service which poses a potential safety and/or personal rights risks to person in care.
POC Due Date: 09/03/2024
Plan of Correction
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2
3
4
Administrator she'll obtain the service. Proof to be submitted by 9/03/24.
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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 08/20/2024 09:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2024 at 07:19 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: GENUINE LOVE CARE HOME
FACILITY NUMBER: 019201168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in S4 and S5 not having LIC503 Health Screening on file which pose potential health, and/or personal rights risks to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
1
2
3
4
Administrator to have S4 and S5 health screened and submit copies of LIC503 by 9/03/24.
Type B
Section Cited
CCR
87412(a)
87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in S5 not having LIC501 Personnel Record which poses a potential personal rights risk to person in care.
POC Due Date: 09/03/2024
Plan of Correction
1
2
3
4
Administrator to have the LIC501 completed and submit copy by 9/03/24.
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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 08/20/2024 09:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2024 at 07:19 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: GENUINE LOVE CARE HOME
FACILITY NUMBER: 019201168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in S3, S4 and S5 not having the required training which pose a potential safety and/or personal rights risks to person in care.
POC Due Date: 09/03/2024
Plan of Correction
1
2
3
4
Administrator stated she'll have the staff complete the number of hours of required training. Self-certification to be submitted by 9/03/24.

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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 08/20/2024 09:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2024 at 07:19 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: GENUINE LOVE CARE HOME
FACILITY NUMBER: 019201168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(3)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and records review, the licensee did not comply with the section cited above in S3, S4 and S5 not having medication training which pose a potential health and/or personal rights risks to person in care.
POC Due Date: 09/03/2024
Plan of Correction
1
2
3
4
Administrator to have the staff trained and submit self-certification by 9/03/24.
Type B
Section Cited
CCR
87411(c)(1)
Regulations
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in S3, S4 and S5 not first aid certified which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
1
2
3
4
Administrator to have the staff registered for training and submit copy of certificates by 9/03/24.
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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 08/20/2024 09:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2024 at 07:19 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: GENUINE LOVE CARE HOME
FACILITY NUMBER: 019201168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above for not doing the drill which poses a potential safety and/or personal rights risks to person in care.
POC Due Date: 09/03/2024
Plan of Correction
1
2
3
4
Adminitrator to have the drill conducted and submit copy by 9/03/24.
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in R1 not having doctor's order for half bed rails which poses a potential safety and/or personal rights risk to person in care.
POC Due Date: 09/03/2024
Plan of Correction
1
2
3
4
Administrator will obtain doctor's order and submit copy by 9/03/24.
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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 08/20/2024 09:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 08/20/2024 at 08:16 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: GENUINE LOVE CARE HOME
FACILITY NUMBER: 019201168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having the R1's 3 medications which were listed on the doctor's order of medications which poses an immediate health and/or personal rights risks to person in care.
POC Due Date: 08/21/2024
Plan of Correction
1
2
3
4
Administrator to check with the doctor if the medications are stiill needed; if not, to obtained discontinued order; otherwise obtain the medications. Proof to be submitted by 8/21/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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