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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201168
Report Date: 11/15/2024
Date Signed: 11/15/2024 02:48:46 PM

Document Has Been Signed on 11/15/2024 02:48 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) 397-2698
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 5CENSUS: 2DATE:
11/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Emelita Dimaguila/AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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On November 6, 2024, Emelita Dimaguila, administrator (ADM), sent a correspondence to Licensing Program Analyst (LPA) Delmundo. Correspondence indicated that resident (R1) who was admitted to the facility on October 25, 2024 and have prescribed medications of which 4 are available over the counter (OTC) were not received. The 4 medications were purchased on November 5, 2024. R1 missed the 4 medications from October 25, 2024 to November 5, 2024.

On this day, November 15, 2024, LPA Delmundo arrived unannounced to conduct a case management in response to the above incident. LPA reviewed R1's file and documents LPA received.

Written Special Incident Report (SIR) was submitted on November 8, 2024. Review of R1's records revealed the following:
1. LIC602A Physician's Report has no doctor's signature.
2. No LIC601 Identification and Emergency Contact Information
3. Facility received R1's P&I according to ADM and facility has not submitted an updated LIC400 Affidavit Regarding Client/Resident Cash Resources nor have obtained Surety Bond coverage.

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 deficiency section 87465(a). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

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

Exit interview conducted. Appeal Rights, LIC421FC, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 11/15/2024 02:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/15/2024 at 12:39 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: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2024
Section Cited
CCR
87465(a)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility.

This requirement is not met as evidenced by:
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Administrator to do the following and submit proof by 11/16/24:
1. Read the Regulations.
2. Come up with a plan of obtaining medications timely.

A $250.00 is assessed.
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-Based on record review, the licensee did not comply with the section above in not obtaining R1's medications timely which posed an immediate health risk to person in care. This is a repeat violation within 12 month period. A citation was issued on 8/20/24.
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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: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/15/2024 02:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/15/2024 at 01:03 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: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87458(a)

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87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. .......
This requirement is not evidenced by:
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Administrator stated she'll bring R1 to the primary care physician on 11/19/24. Copy of LIC602A to be submitted by 11/29/24.
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-Based on interview and record review, the licensee did not comply with the section above in not obtaining medical assessment/LIC602A Physician's Report prior to admission which poses a potential health risk to person in care.
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Type B
11/29/2024
Section Cited
CCR87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
-This requirement is not evidenced by:
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Administrator to complete the LIC601 and submit copy by 11/29/24.
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-Based on record review, the licensee did not comply withn the section above in not having LIC601 for R1 which poses a potential health 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: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/15/2024 02:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/15/2024 at 01:18 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: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87216(a)(1)

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87216 Bonding
(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. (1)The

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Administrator to obtain surety bond coverage and submit proof by 11/29/24.
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amount of the bond shall be in accordance with the following schedule......
-This requirement is not evidenced by:
-Based on interview and observation, the licensee did not comply with the section above in not obtaining surety bond coverage which poses a potential personal rigths risk...
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Type B
11/29/2024
Section Cited
CCR87208(a)(9)

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87208 Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval..
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Administrator to submit an updated LIC400 by 11/29/24.
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(9) A statement whether or not the applicant will handle residents' money.....
This requirement is not met as evidenced by:
-Based on observation, interview and record review, the licensee did not comply with the section above in not submitting an updated LIC400.
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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: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/15/2024 02:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/15/2024 at 01:48 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: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted.... within seven days of the occurrence of any of the events...(D) Any incident which threatens
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Corrected.
Report submitted on 11/08/24.
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 the welfare, safety or health of any resident...
-This requirement is not met as evidenced by:
-Based on document review, the licensee did not comply with the section in not submitting an incident report in timely manner which posed a potential health 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: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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