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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201451
Report Date: 01/10/2025
Date Signed: 01/10/2025 03:42:19 PM

Document Has Been Signed on 01/10/2025 03:42 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:ESCUETA CARE HOME 2FACILITY NUMBER:
019201451
ADMINISTRATOR/
DIRECTOR:		ESCUETA,MILANETTEFACILITY TYPE:
740
ADDRESS:1889 WEST STREETTELEPHONE:
(510) 940-8652
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 5DATE:
01/10/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Milanette Escueta/Applicant-Administrator
and Adrian Escueta/Assistant Administrator 		TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At 11:45 am on this day, January 10, 2025, Licensing Program Analyst (LPA) Delmundo conducted a pre-licensing inspection, and met with Milanette Escueta, applicant-administrator, and Adrian Escueta, assistant administrator. License application is for six (6) total capacity all non-ambulatory. Fire clearance was granted on November 17, 2024. The facility is currently in operation and application is for change of ownership.

Applicant submitted the LIC9282 Infection Control Plan and updated LIC610E Emergency Disaster Plan to Central Application Bureau (CAB) analyst.

LPA toured the facility inside out with the applicant and assistant administrator. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the kitchen, dining room, laundry area, staff room, bedrooms, bathrooms, front and side yard. Bedrooms were observed appropriately furnished with adequate lighting and drawers. The facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed adequate for residents' use. There’s 7 days supplies of non-perishables and 2 days of perishables. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. Storages for knives and medications were observed locked. Bathrooms/shower areas were observed with grab bars and non-skid mats.

Fire extinguishers were observed fully charge and tags showed serviced March 19, 2024. Facility has carbon monoxide and smoke detectors that were tested, and observed operational. First aid kit inspected and observed complete with manual. Facility has flash lights for emergency lighting. Hot water temperature in the common bathroom was tested and measured at 110.7 degrees Fahrenheit.

...continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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 2
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: ESCUETA CARE HOME 2
FACILITY NUMBER: 019201451
VISIT DATE: 01/10/2025
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Ombudsman and complaint posters, Right to Resident Council, Right to Family Council, Theft and Loss Program/Policy and Residents Personal Rights were observed posted in the prominent place.

LPA observed the following:
-at 11:55 a.m., expired salad dressing and mustard and rotten head lettuce. Staff threw the expired items.
-at 12:05 p.m., sides of cabinets by cooking range greasy.
-at 12:10 p.m., nail polish remover, ant and roach killer and chest rub in unlocked staff room. Staff locked the staff room.
-at 12:20 p.m., moldy shower areas in common and ensuite bathrooms.
-at 12:25 p.m., gallons of paint, oxygen tank, construction materials such as grout, grout cleaner, stain and rust remover in unlocked storage. Staff locked the storage.
-at 12:26 p.m., area rug and weight machine in the side yard.

Applicant stated the following:
1. Will have the cabinets cleaned and install metal on the side of the cabinets.
2. Will have the showers cleaned.
3. Will have the area rug and weight machine discarded.
Proof of corrections/pictures to be submitted by January 24, 2025.

LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application, and license to be granted by CAB analyst.

Applicant was reminded to update the following upon granting of license:
1. Admission Agreements for all residents and to use the Admission Agreement approved by CAB analyst for all resident.
2. LIC601 Identification and Emergency Contact Information with the new license/facility number.

Exit interview conducted, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
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