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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005336
Report Date: 10/17/2022
Date Signed: 10/18/2022 09:05:03 AM

Document Has Been Signed on 10/18/2022 09:05 AM - 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:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maybelyn Magsayo-Ugale TIME COMPLETED:
12:30 PM
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On 10/17/2022 at 10:15am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual infection control visit. LPA Pascua was greeted by staff member, Michael Gamboa and was asked to call the Administrator, Maybelyn Magsayo-Ugale to let her know that licensing was present at this time. Upon arrival the LPA observed a centralized screening point equipped with hand sanitizer and masks. Shortly after, LPA Pascua met with Administrator Ugale explained the purpose of the visit. The purpose of the visit is to conduct an annual infection control visit. This facility is licensed for 6 non-ambulatory residents and has a hospice waiver for 2. The administrator has an active certificate #6026752740 and expires on 09/17/2023. There were 4 other staff members present at this time, Michael Gamboa. Theresita Alvarez, Nora Casaverde, and Rosita Curilan.
At 10:30am, LPA Pascua initiated a tour with Administrator Ugale.
At 10:35am, LPA Pascua toured the laundry room and garage. Washer and Dryer were observed to be in good repair. A linen closet was identified in the garage and was observed to be a sufficient amount of linens for 6 residents at this time. LPA observed toxins, laundry detergent and other supplies to be in locked cabinets located in the garage and made inaccessible to the residents in care.
At 10:45am, LPA Pascua toured the kitchen. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food supply. Kitchen cabinets, appliances, and sink were observed to be in good repair. LPA observed knives to be located in a closet located in the hallway next to the kitchen. A fire extinguisher located in the kitchen was observed to be serviced by a local fire company, Armor Fire Co. on 06/28/2022.
At 10:50am, LPA Pascua toured the dining room and living room. Windows, blinds, and screens were in good repair. Furniture and furnishings intended for resident use were observed to be in maintained and in good repair.
At 10:55am-11:10am, LPA Pascua toured 3 shared resident bedrooms. Resident furniture was observed to be sufficient to meet their needs at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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: 10/17/2022
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At 11:15am, LPA toured two resident bathrooms. Hot water temperature was measured to be 112 degrees. Grab bars were observed to be stable and in good repair at this time.
At 11:20am, LPA Pascua toured the live-in staff bedrooms and bathrooms.
At 11:25am, LPA Pascua toured the exterior of the physical plant. Perimeter fence was observed to be stable and gates were in good repair.
At 11:30-11:45 am, LPA Pascua observed a locked centralized stored medication cabinet located in the kitchen. Along with the Administrator Ugale, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

Based on the observations made on this visit, an immediate civil penalty of $1000 was assessed for a violation of Section 80019(e)(2). This civil penalty was based on criminal record clearance transfer violation. The Licensee stated that S1 and S2 was working prior to obtaining her criminal record clearance transfer and has not done the paperwork prior to working at this facility.

As a result of this visit, the following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

An exit interview was conducted. A copy of the 809, 809-C, 809-D, LIC421BG and appeal rights were printed and a copy was given to the facility designated Administrator, Maybelyn Magsayo-Ugale. The licensee was informed that a failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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Document Has Been Signed on 10/18/2022 09:05 AM - It Cannot Be Edited


Created By: Arielle Pascua On 10/17/2022 at 11:35 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: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(2)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Licensee did not comply with the section cited above by not associating S1 and S2 to RM Ugale Care Home prior to working at the facility. This poses a potential health, safety, or personal rights risk to the persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Licensee will submit all required documentation to the Department in order to associate S1 to RM Ugale Care Home. The licensee shall maintain verification that it was submitted on file.
The licensee shall follow-up with LPA via email to ensure that S2 is associated by POC Date 10/24/2022.
Type B
Section Cited
CCR
80075(6)(D)
80075 Health Related Services
(D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the Licensee did not obtain a written order and maintain in the clients file from the physician for R1's Vitamin C medication. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Licensee will obtain phsyician's written order and maintain a copy in the clients file. Licensee will provide a copy of the physicans order to the LPA's email by POC date 10/24/2022.
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:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


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