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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601400
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:59:55 PM


Document Has Been Signed on 10/25/2022 12:59 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:A AND M BOARD&CARE,INNOVATIVE ASSIS.HOME FOR ELDERFACILITY NUMBER:
015601400
ADMINISTRATOR:GACOTE, ALEC F.FACILITY TYPE:
740
ADDRESS:2480 ALMADEN BLVD.TELEPHONE:
(510) 429-8630
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH: Maria Erolin, LicenseeTIME COMPLETED:
01:12 PM
NARRATIVE
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On 10/25/2022 at 10:50 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Licensee Maria Erolin and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks.

The following deficiency was observed during the visit:
LPA observed the fire extinguisher was last serviced on June 3 2021
LPA observed a resident was living in shared living space and did not have their own room
LPA observed one of the sinks in the bathroom was not working


The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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 3


Document Has Been Signed on 10/25/2022 12:59 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: A AND M BOARD&CARE,INNOVATIVE ASSIS.HOME FOR ELDER
FACILITY NUMBER: 015601400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

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 a resident living in a room that is not a dedicated bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2022
Plan of Correction
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The facility will move the resident into one of the bedrooms. Proof of correction will be sent to CCLD by POC date.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/25/2022 12:59 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: A AND M BOARD&CARE,INNOVATIVE ASSIS.HOME FOR ELDER
FACILITY NUMBER: 015601400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

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 one of the sinks in the bathroom not working properly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2022
Plan of Correction
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The facility will have the sink repaired. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or 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 a fire extinguisher service tags dated 06/03/2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2022
Plan of Correction
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Facility will either have fire extinguisher serviced or purchase a new fire extinguisher and tape receipt to fire extinguisher. A photo will be sent to CCLD by POC date.

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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