<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441012
Report Date: 03/22/2024
Date Signed: 03/22/2024 07:19:47 PM

Document Has Been Signed on 03/22/2024 07:19 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: 4DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Staff Jose 'Jay' Fernandez
and Milagros 'Mel' Fernandez		TIME COMPLETED:
07:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 4:30 p.m. on this day, March 22, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Staff Jose 'Jay' Fernandez and
Milagros 'Mel' Fernandez, and informed the reason for visit. LPA called and spoke over the phone with Victoria Canovas, administrator, who stated she can not come to the facility, and authorized Milagros Fernandez to be with LPA during inspection and sign and receove this report.

Facilty has LIC808 Mitigation Plan. LPA requested on 2/28/23 to submit the LIC9282 Infection Control Plan, but administrator has not submitted up to this day.

LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, garage, side and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and storage for cleaning supplies were observed locked.

Facility has carbon monoxide and smoke detectors that were tested and observed functional. Facility conducts fire and earthquake drills at least every quarter, and records showed fire drill last conducted 3/19/24. Hot water temperature in the one of the bathrooms was tested.

LPA observed the following:
-at 4:47 p.m., room added in the sun/recreation room.
-at 4:48 p.m., construction tools and materials in the sun room.
-at 4:49 p.m., rusted screen door, window screen, pieces of wood and metal, rusted pails of paint, rusted barbecue grill, worn out couch and chair in the backyard.

...continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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 10
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: 03/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2

-at 5:03 p.m., hot water at 121 degrees Fahrenheit.
-at 5:07 p.m., trash cans without lids on the hallway on the second floor and in resident's room

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty for fire safety violation of section 80020(a) for room addition is assessed on this day and will continue for $100.00 per day until corrected. Any repeat violations within 12 month period may result in civil penalties.

Deficiencies, plan and proof of corrections, and civil penalty were discussed with the administrator over the phone in the presence of the staff.

Administrator to submit the following current/updated documents by April 5, 2024.
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage.

Due to time constraint, LPA will come back to continue the inspection.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.


SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 03/22/2024 07:19 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/22/2024 at 06:24 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: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in construction tools and materials in the sun room which pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2024
Plan of Correction
1
2
3
4
Staff locked the items.
In addition. administrator to in-serviec the staff, and submit proof by 3/23/24.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) 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
1
2
3
4
Based on odservation, the licensee did not comply with the section cited above in adding room in the sun room which poses an immediate safety risk to persons in care.

A $500,00 civil penalty is assesed.
POC Due Date: 03/23/2024
Plan of Correction
1
2
3
4
Administrator stated she'll have the room demolished. Picture to be submitted by 3/23/24.
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: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 03/22/2024 07:19 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/22/2024 at 06:24 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: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in rusted screen door, window screen, pieces of wood and metal, rusted pails of paint, rusted barbecue grill, worn out couch and chair in the backyard. These pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
Administrator to have the yard cleaned, abd submit pictures by 4/05/24.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in hot water was at 121 degrees Fahrenheit.which poses a potential safety and/or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
Administrator to have the water temperature adjusted and submit picture by 4/05/24.
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: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 03/22/2024 07:19 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/22/2024 at 06:24 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: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in trash cans without lids on the hallway on the second floor and in resident's room which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
Administrator to purchase trash cans with foot pedal operated lids, and submit proof of purchase by 4/05/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10