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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005336
Report Date: 09/09/2021
Date Signed: 09/09/2021 04:25:01 PM

Document Has Been Signed on 09/09/2021 04:25 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:RM UGALE CARE HOMEFACILITY NUMBER:
397005336
ADMINISTRATOR:MAGSAYO-UGALE, MAYBELYNFACILITY TYPE:
740
ADDRESS:110 E. MT. DIABLO AVENUETELEPHONE:
(209) 836-5215
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 6CENSUS: 6DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:MAGSAYO-UGALE, MAYBELYN, AdministratorTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced Annual/ Infection Control visit on this date. LPA was greeted by caregiver, Andres Villaluz. (C1). LPA met with MAYBELYN MAGSAYO-UGALE, Administrator (AD). Administrator Certificate valid until 9/17/2021.

LPA and C1 inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, laundry room, and dining room area. LPA observed sufficient seven days non-perishable and two days perishable food supplies in the main kitchen. LPA observed sharps and centrally stored medications locked in pantry closet.

Hot water temperature was measured in residents' bathroom with C1 at 120 degrees which is in required range of 105 to 120 degrees. LPA observed there was a Carbon Monoxide/ Fire monitors in facility. Fire extinguisher maintained on 6/23/21.
LPA reviewed 3 staff and 5 resident files. Resident files were incomplete. LPA observed missing preappraisals, incomplete emergency contact.

All persons in facility fully vaccinated with exception to 1 staff due to personal reasons. LPA observed staff wearing masks. LPA observed 30 days PPE supply in laundry room.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336
VISIT DATE: 09/09/2021
NARRATIVE
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Upon entry, caregivers did not conduct symptom/temperature check until requested by LPA. No sanitizer or thermometer were observed. LPA observed no masks available to visitors. Sign in sheets were observed to document date and visitors name. Sign in sheets did not include symptom screening for reporting requirements to public health officer and contact tracing.

LPA observed in oxygen for a resident on hospice. No Oxygen signs posted.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/09/2021 04:25 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 09/09/2021 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2021
Section Cited

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(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (1) Conduct an interview with the applicant and his responsible person.
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above there were no pre-admission assessments or interviews which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/20/2021
Section Cited

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(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above there were no pre-admission assessments or interviews which poses/posed a potential health, safety or personal rights risk to persons 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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2021 04:25 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 09/09/2021 at 01:11 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2021
Section Cited

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87506 Resident Records


(b) Each resident’s record shall contain at least the following information:
(8) Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency.
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above there were no updated emergency contact information for each resident or information was missing which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
09/20/2021
Section Cited

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87705 (I)(8)
Care of Persons with Dementia. Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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This requirement was not met as evidenced by records reviewed, facility did not have record of fire Drill log. Caregiver. Licensee had no record to provide to LPA. LPA was unable to determine when the last disaster drill was conducted as required. This poses a potential safety risk to the residents 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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021


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Page: 4 of 5
Document Has Been Signed on 09/09/2021 04:25 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 09/09/2021 at 01:14 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
Section Cited

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87618 (b)(3)(B) Oxygen Administration - Gas and Liquid - Oxygen in Use signs shall be posted in appropriate areas.
(As identified in 87101: (E) Maintenance of house rules for the protection of residents)
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This regulation was not met by evidence by:
Based on observation, AD did not ensure posting of oxygen in use signs of the resident(s) rooms that had oxygen.
This poses an immediate threat to the residents in care.
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Type B
09/20/2021
Section Cited

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87464 (f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
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This regulation was not met by evidence by: A sign-in policy and PPE supplies available upon entry was not enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing).
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021


LIC809 (FAS) - (06/04)
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