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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441012
Report Date: 03/18/2026
Date Signed: 03/18/2026 03:09:45 PM

Document Has Been Signed on 03/18/2026 03:09 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/
DIRECTOR:		CANOVAS, VICTORIA R.FACILITY TYPE:
735
ADDRESS:22968 MAUD AVENUETELEPHONE:
(510) 530-3037
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 4DATE:
03/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Mary Anne Weber/Staff TIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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On this day, March 18, 2026, at 11:35 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Milagros 'Mel' Fernandez, and informed the reason for visit. LPA called and spoke over the phone with Victoria 'Vickie' Canovas, administrator (ADM). ADM authorized Milagros Fernandez to be with LPA in touring the facility as ADM cannot come to the facility. The other staff, Mary Anne Weber, arrived at around 12:12 pm as Jose 'Jay' Fernandez and Milagros Fernandez have to go with the 4 residents for an outing.

LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, sun/recreation room, front, 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 in operating condition on this day. Facility conducts fire and earthquake drills at least every quarter, and records showed fire drill last conducted January 21, 2026 and earthquake drill January 19, 2026. Fire extinguishers checked, observed fully charge with tags showed serviced March 6, 2025. LPA advised to have them serviced within this month. Hot water temperature in the one of the bathrooms was tested. First aid kit was observed complete with manual.

LPA reviewed 4 residents records.


........continued 809C (page 2)
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CANOVAS HOME
FACILITY NUMBER: 011441012
VISIT DATE: 03/18/2026
NARRATIVE
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LPA observed the following:
-at 11:53 am, garden tools including but not limited to shears, hammer, shovel in unlocked storage in the side yard.
-at 11:59 am, hot water at 128.8 degrees Fahrenheit.
-staff file not available for review.
-at 12:30 pm, residents (R1 and R2) LIC602 Physician's Report on file are over a year old.
-from 1:00 pm to 1:30 pm, all 4 clients do not have LIC625 Appraisal/Needs and Services Plan and LIC9172 Functional Capability Assessment on file. on file.
-resident's (R4) medical assessment (Physician's Report) on file is more than 2 years old.
-Mary Anne Weber stated she does not have access to residents' medications, therefore LPA was unable to check and compare the medications in facility's hand with doctor's orders.

LPA called and left message on administrator's (ADM) voice mail in the presence of Mary Anne Weber informing ADM of the deficiencies and plan and proof of corrections. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty.

Administrator to submit the following current/updated documents by April 1, 2026:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/18/2026 03:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/18/2026 at 02:01 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: 03/18/2026

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
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Based on observation, the licensee did not comply with the section cited above in garden tools in unlocked storage in the side yard which pose an immediate safety and/or personal rights risks to persons in care.
POC Due Date: 03/19/2026
Plan of Correction
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Staff locked the storage.
In addition, administrator to do in-service training and submit copy of training topic with attendees signatures by 3/19/26.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(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
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Based on observation, the licensee did not comply with the section cited above inhot water at 128.8 degrees Fahrenheit which poses an immediate health, safety and/or personal rights risks to persons in care.
POC Due Date: 03/19/2026
Plan of Correction
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Administrator to have the temperature adjusted within Regulation range and submit proof by 3/19/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2026 03:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/18/2026 at 02:01 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: 03/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above in all staff records/file not available and/or site for review which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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Administrator to read the Regulation and ensure files will be made availalble. Self-certification to be submitted by 4/01/26.
Type B
Section Cited
HSC
1507(c)(1)(B)
General Provisions
(1) For regional center clients the following shall apply: (B) The client's individualized health care plan shall be reassessed at least every 12 months or more frequently as determined by the client's physician or nurse practitioner during the time the client receives incidental medical services in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on records review, the licensee did not comply with the section cited above in residents' (R1 and R2) LIC602 Physician's Report on file over a year old which pose a potential health, and/or personal rights risks to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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Administrator to have the medical assessments updated and submit copies by 4/01/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/18/2026 03:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/18/2026 at 02:01 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: 03/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in all 4 residents not having LIC9172 Functional Capability Assessment on file which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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Administrator to complete the LIC9172 and submit copies by 4/01/26.
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on records review, the licensee did not comply with the section cited above in alll 4 residents not having LIC625 Appraisal/Needs and Services Plan on file which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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Administrator to complete the LIC625 and submit copies by 4/01/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/18/2026 03:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/18/2026 at 02:01 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: 03/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in resident's (R4) medical assessment (Physician's Report) on file more than 2 years old which poses a potential health, safety and/or personal rights risks to person in care.
POC Due Date: 04/01/2026
Plan of Correction
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2
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Administrator to have call R4's doctor for an appointment and have an LIC602A Physician's Report completed. Copy to be submitted by 4/01/26.
Type B
Section Cited
CCR
80075(b)(5)(B)
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: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in staff who stayed with LPA not having access to medications for LPA to check and compare with doctor's orders which pose potential health, and/or personal rights risks to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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2
3
4
Administrator to read the Regulation and self-certify compliance by 4/01/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2026


LIC809 (FAS) - (06/04)
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