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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441012
Report Date: 04/03/2024
Date Signed: 04/03/2024 07:08:40 PM

Document Has Been Signed on 04/03/2024 07:08 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:
ADMINISTRATOR/
DIRECTOR:		CANOVAS, VICTORIA R.FACILITY TYPE:
735
ADDRESS:22968 MAUD AVENUETELEPHONE:
(510) 530-3037
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 4DATE:
04/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Staff Jose 'Jay' Fernandez
and Milagros 'Mel' Fernandez		TIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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At 11:50 a.m. on this day, April 3, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual inspection that was started on March 22, 2024. LPA met with 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 arrived at around 12:30 p.m.

LPA interviewed 2 residents and 2 staff, and reviewed 4 residents and 3 staff files. Medications were inspected and compared with doctor's orders and medications in facility's hand. Residents' P&I were checked and compared with last recorded balance.

LPA observed the following:
-at 1:00 p.m., Victoria Canovas' administrator's certificate on file expired 4/06/23, LPA checked the Community Care Licensing website for Active and Pending Lists, and Canovas is not on the lists.
-at 2:00 p.m., residents' (R1 and R2) P&Is have no LIC405 Record of Client's/Resident's Safeguarded Cash Resources on file.
-at 3:35 p.m., one of resident's (R3) medications has double entries on LIC622 Centrally Stored Medication and Destruction Record. R3's medicated shampoo has no doctor's order on file.
-at 4:15 p.m., resident's R2, R3 and R4's LIC625 Appraisal/Needs and Services Plan were over 4 years old.

Deficiencies, and plan and proof of corrections were discussed with the administrator. 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.

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: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 04/03/2024 07:08 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/03/2024 at 05:28 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: 04/03/2024

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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4
Based on record review, the licensee did not comply with the section cited above in administrator's certificate expired which poses a potential personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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2
3
4
Administrator stated she'll check with Administrator Certification Bureu if the documents and payment for renewal she submitted on 3/2023 were received. Proof to be submiited by 4/17/24.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in R2, R3 & R4's LIC625 over 4 years old which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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4
Administrator to update the LIC625s and submit self-certification by 4/17/24.
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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 04/03/2024 07:08 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/03/2024 at 05:28 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: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in R3's medicated shampoo without doctor's order on file which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator to obtain doctor's order, and submit copy by 4/17/24.

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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 04/03/2024 07:08 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/03/2024 at 05:40 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: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, he licensee did not comply with the section cited above in 1 of resident's (R3) medications has double entry on LIC622 Centrally Stored Medication and Destruction Record. which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Corrected.
Type B
Section Cited
CCR
80026(h)(1)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:
(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.
-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 in R1 and R2’s P&I not having LIC405 on file which pose a potential personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator to complete the LIC405s, and submit copies by 4/17/24,
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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


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