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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441012
Report Date: 02/28/2023
Date Signed: 02/28/2023 02:17:44 PM

Document Has Been Signed on 02/28/2023 02:17 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:CANOVAS HOMEFACILITY NUMBER:
011441012
ADMINISTRATOR:CANOVAS, VICTORIA R.FACILITY TYPE:
735
ADDRESS:22968 MAUD AVENUETELEPHONE:
(510) 530-3037
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 5DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Staff Jose 'Jay' Fernandez and
Milagros 'Mel' Fernandez		TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Jose 'Jay' Fernandez and Milagros 'Mel' Fernandez, and informed the purpose of visit. Victoria Canovas, licensee-administrato, r is not available, so LPA called and spoke over the phone with Margarita 'Rita' Revill , acting administrator, who authorized the staff to be with LPA during inspection, and sign and receive this report.

LPA toured the facility inside out with Milagros Fernandez. LPA inspected the living room, dining area, kitchen, sun room, residents bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. Central storage for medications was observed locked.
LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked. Facility has antigen test kits readily available. COVID-19 signages were observed in some areas of the facility. Bathroom lavatories were observed with liquid soap. Trash cans were observed with no touch lids.

Fire extinguisher checked, and observed fully charge with tag showed serviced February 25, 2022. Milagros Fernandez, the licensee is scheduled to have it service. Hot water temperature in one of the common bathrooms was tested, and measured at 116.4 degrees Fahrenheit.

LPA observed the following:
1. Two dowels at foot of sliding door in the sun room which prevents the door from opening from inside.

.......continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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 6
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: CANOVAS HOME
FACILITY NUMBER: 011441012
VISIT DATE: 02/28/2023
NARRATIVE
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Page 2

2. Sun room: cluttered with boxes and crate of files, old vinyl records, tape recorders, rolled area rug, two garbage bags full of empty water bottles, old magazines, large empty boxes, big boxes of supplies of adult pads
3. Backyard: screen door; broken drawers, tv stand and office chairs; rusted metal chairs; pieces of wood with protruding metal screws; broken stand fan
4. Side yard: files of wet empty boxes; broken cabinets; pet kennel; broken oven toaster & freezer; wet red luggage
5. Unlocked cabinets on the first floor bathroom where cleaning supplies including but not limited to glass cleaner and Lysol are kept; wood glue; rubbing alcohol, Homopathic medicine cream
6. Medicines in unlocked staff bedroom.
7. No 'Wear Mask' poster on the front entrance door and living room. No COVID-19 signages on the front door.
8. No supplies of N95 respirators and disposable gowns. Only 50 pieces of surgical masks, not sufficient for four staff (including administrator) for 30 days.
9. Staff not wearing mask.
Licensee-administrator to submit the following by March 14, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety bond coverage
5. Current N95 fit testing records/certificates
6. LIC9282 Infection Control Plan

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for section # 80020(a). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Margarita Revill over the phone. Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form and copy of this report provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/28/2023 02:17 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2023 at 01:39 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: CANOVAS HOME
FACILITY NUMBER: 011441012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020(a)
Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having dowels on the sliding door which was not originally approved by the fire department which poses an immediate safety and personal rights risks to persons in care.
POC Due Date: 03/01/2023
Plan of Correction
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Staff removed the dowels during inspection.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/01/23.
$500 Civil Penalty was assessed.
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for unlocked bathroom cabinets with cleaning supplies and medications, and medications in unlocked staff bedroom which pose an immediate health and safety risks to the persons in care..
POC Due Date: 03/01/2023
Plan of Correction
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Staff locked the cabinets and staff bedroom during inspection
In addition, administrator to in-service the staff, and submit copy of training topic with attendees signatures by 3/01/23.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/28/2023 02:17 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/28/2023 at 01:48 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: CANOVAS HOME
FACILITY NUMBER: 011441012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for cluttered sun room, backyard and side yards full of broken items and debris which poses an potential safety and personal rights risks to the persons in care.
POC Due Date: 03/14/2023
Plan of Correction
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Administrator to have the sunroom cleared of clutters and clean the side and backyard. Pictures to be submitted by 3/14/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023


LIC809 (FAS) - (06/04)
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