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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005336
Report Date: 12/20/2021
Date Signed: 12/20/2021 04:12:37 PM

Document Has Been Signed on 12/20/2021 04:12 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: 4DATE:
12/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Mabelyn Magsayo-Ugale, AdministratorTIME COMPLETED:
02:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to RM Ugale for the purpose of opening a Case Management. LPA met with Mabelyn Magsayo-Ugale, Administrator.

During records reviewed, LPA observed a resident admitted into the care home without the proper admission agreement completed and signed by the responsible party. The resident had no paperwork for emergency contacts. .LPA observed the resident did not have a physicians report or 602 prior to moving into the home. Interviews with care staff anf administrator conducted confirm the care staff and administrator had no understanding of the medical needs of the resident.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview conducted with Mabelyn Magsayo-Ugale, Administrator and a copy of this report was provided.. .
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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
Document Has Been Signed on 12/20/2021 04:12 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 12/20/2021 at 11:49 AM
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: 12/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2021
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. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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Licesnee will write a letter acknowleding understanding of regulation and submit to LPA by POC date.
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This regulation was not met as evidence by, licensee did not ensure to obntain an 602 or physcians reportt prior to accepting the resident. This poses an immediate risk to resident in care.
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Type B
12/29/2021
Section Cited
CCR87507(a)

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87507 Admission Agreements

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
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Licesnee will write a letter acknowleding understanding of regulation and submit to LPA by POC date.
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This regulation was not met as evidence by, licensee did not ensure to obntain an addmission agreement prior to accepting the resident. This poses an potential risk to resident 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: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2021


LIC809 (FAS) - (06/04)
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