015601368-3-7-2023-15-AS-LFOA-CPQ2QE-20230307163549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601368
Report Date: 03/07/2023
Date Signed: 03/07/2023 04:36:11 PM

Document Has Been Signed on 03/07/2023 04:36 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:	AGEWAY BOARDING CARE		FACILITY NUMBER:	015601368
ADMINISTRATOR:	DAYEH, VICTORIA & ANA		FACILITY TYPE:	740
ADDRESS:	2716 MEADOWLARK DRIVE		TELEPHONE:	(510) 475-8869
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 3	DATE:	03/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ana Dayeh, Administrator		TIME COMPLETED:	04:45 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	On this day at around 9am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility to conduct annual required inspection. LPA was met by caregivers Zenaida and Renato Tisico. Administrator Ana Dayeh arrived at a later time. LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, garage dining and living areas. The facility has 4 bedrooms and 2 bathrooms. One bedroom is designated as staff room. There are 3 residents and 2 of 3 are on hospice care. Facility has an approved fire clearance for 6 non ambulatory residents. Two fire extinguishers last serviced on 5/3/2022 were observed. Facility has sufficient supply of perishable and non-perishable foods. There are 2 staff working during the visit and both are fingerprint cleared. Bathrooms were observed with grab bars and non skid mats. LPA reviewed 3 resident and 3 staff files and interviewed 3 residents and 2 staff. Facility has wired carbon monoxide and smoke detector that were observed functional. Facility has a current liability insurance. At approximately 9:20am, LPA observed Comet cleanser unlocked under the sink. At approximately 9:30am, LPA observed hot water measured at 132.6F. At approximately 11am, LPA observed cleaning chemicals unlocked in the garage. While conducting staff file reviews at around 11:30am, LPA observed staff do not have current CPR training. Deficiencies are being cited today in violation of California Code of Regulations and follows on 809D. Failure to submit proof of corrections (POC's) along with LIC9098 by plan of correction due dates may result in civil penalty. * continuation on Lic 809C*

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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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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: AGEWAY BOARDING CARE	FACILITY NUMBER: 015601368
	VISIT DATE: 03/07/2023

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	Exit interview was conducted with Administrator and Appeal Rights was provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2023 04:36 PM - It Cannot Be Edited

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: AGEWAY BOARDING CARE	FACILITY NUMBER: 015601368
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 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. Hot water measured at 132.5F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2023
	Plan of Correction
1 2 3 4	Administrator adjusted hot water to 115F. Deficiency was cleared during inspection.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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. Cleaning chemicals were observed unlocked and accessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2023
	Plan of Correction
1 2 3 4	Chemicals were locked during inspection. Deficiency was cleared during inspection.

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2023 04:36 PM - It Cannot Be Edited

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: AGEWAY BOARDING CARE	FACILITY NUMBER: 015601368
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. No staff has a current CPR training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will submit to CCL proof of staff CPR training.

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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