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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011405838
Report Date: 02/08/2024
Date Signed: 02/08/2024 06:05:11 PM

Document Has Been Signed on 02/08/2024 06:05 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:ABLELIGHT, INC - MOWRYFACILITY NUMBER:
011405838
ADMINISTRATOR:CHRISTINA O QUINTANAR-SANCFACILITY TYPE:
735
ADDRESS:1335 MOWRY AVETELEPHONE:
(510) 505-1245
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 12CENSUS: 10DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Fidel De Castro, Lead DSP 2TIME COMPLETED:
06:15 PM
NARRATIVE
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On 2/8/2024 at 12:55PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Lead DSP 2, Fidel De Castro and explained the purpose of the visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke detectors are interconnected. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 12/16/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 113.1 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathroom. There were adequate lights in each room. First Aid kit is complete. No bodies of water observed. Indoor and outdoor passageways were free of obstruction. LPA reviewed 4 clients and 3 staff files starting at 2:00PM.

At 2:45PM, LPA observed C1 does not have a current IPP or Re-appraisal/ Needs and Service Plan.

At 3:30PM, LPA observed Administrator Certificate was expired on 12/6/2022. LPA reviewed CCLD website and did not find administrator on active or pending list. LPA was informed that Administrator did not submit renewal to CCLD.

At 4:00PM, LPA observed S2 does not have TB test results on file.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

LPA will return at a later time to complete the inspection.

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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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Document Has Been Signed on 02/08/2024 06:05 PM - It Cannot Be Edited


Created By: Grace Luk On 02/08/2024 at 05:12 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: ABLELIGHT, INC - MOWRY
FACILITY NUMBER: 011405838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not having an administrator with current administrator certificate which poses a potential health and safety risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Facility has agreed to create a written plan to have an administrator with current administrator certificate and submit the plan to CCLD by POC date.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having TB test result for S2 which poses a potential health and safety risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Facility has agreed to obtain TB test result for S2 and submit a copy to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/08/2024 06:05 PM - It Cannot Be Edited


Created By: Grace Luk On 02/08/2024 at 05:31 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: ABLELIGHT, INC - MOWRY
FACILITY NUMBER: 011405838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.2(b)(1)
(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:
(1) The needs appraisal or IPP is not more than one year old.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current IPP or appraisal for C1 which poses a potential health and safety risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Facility has agreed to obtain current IPP or appraisal (LIC625) for C1 and submit a copy to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


LIC809 (FAS) - (06/04)
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