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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601481
Report Date: 05/16/2022
Date Signed: 05/16/2022 05:19:59 PM


Document Has Been Signed on 05/16/2022 05:19 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:COMMON DESTINYFACILITY NUMBER:
015601481
ADMINISTRATOR:TOM, MARVINFACILITY TYPE:
740
ADDRESS:34209 SYLVESTER DRIVETELEPHONE:
(510) 794-4931
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY:6CENSUS: 5DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Marvin Tom, AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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On 5/16/2022 at 11:20AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with house manager, Leonora Maquilan. Administrator, Marvin Tom arrived about 2 hours later.

Upon entry, staff checked LPA's temperature. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPA observed cough etiquette, social distancing, and signs & symptoms posted in the common area. All sinks and bathrooms were equipped with soap and paper towel. Hand washing signs were posted in bathrooms.

During record review, LPA observed visitors log. LPA observed facility has a copy of Mitigation Plan on file. Staff was FIT tested for N95 masks and certificates were reviewed. LPA observed PPEs, food supplies, and paper supplies are sufficient.

At 12:00PM, LPA observed unlocked cleaning supply under the kitchen sink. Knives drawer in the kitchen was unlocked. Unlocked gardening tools were observed. Staff locked up knives, cleaning supplies, and gardening tools during inspection.

At 12:30PM, LPA observed medication room was unlocked. Staff locked up medication room during visit.

At 12:45PM, LPA observed R1 has full bed rails and was not on hospice care. R2 and R3 recently graduated from hospice and still had full bed rails.

(Continue on LIC809C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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 8


Document Has Been Signed on 05/16/2022 05:19 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: COMMON DESTINY
FACILITY NUMBER: 015601481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies, gardening tools, and knives which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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Staff locked up the cleaning supplies, gardening tools, and knives during inspection.

Deficiency cleared.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 unlocked medication and medication room was unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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Staff locked up medication room during inspection.

Deficiency cleared.

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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8


Document Has Been Signed on 05/16/2022 05:19 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: COMMON DESTINY
FACILITY NUMBER: 015601481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 full bed rails for residents who are not on hospice care which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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Administrator has agreed to remove full bed rails for the three residents and submit picture proof to CCLD by POC date.
Type A
Section Cited
CCR
87468.1(a)(6)
Personal Rights of Residents in All Facilities
(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.

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 by locking side gate at night which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/17/2022
Plan of Correction
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Staff removed lock during inspection.

Deficiency cleared.

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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 05/16/2022 05:19 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: COMMON DESTINY
FACILITY NUMBER: 015601481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 vertical blinds in disrepair and items in various places in the back yard space, especially near the RV which poses a potential health and safety risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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Administrator has agreed to repair the vertical blinds and remove items in the back yard. Administrator will submit picture proof of repairs and removals to CCLD by POC date.
Type B
Section Cited
CCR
87208(a)(7)(A)
Plan of Operation
(7) Sketches, showing dimensions, of the following:
(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e)

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 by not updating facility sketch to included staff room, office room in garage, and RV occupied in the backyard which poses a potential health and safety risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Administrator has agreed to provide a new facility sketch and yard sketch to include the staff room, office room in garage, and RV in the backyard. Administrator will submit new facility, yard sketch, and permit for the garage 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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8


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: COMMON DESTINY
FACILITY NUMBER: 015601481
VISIT DATE: 05/16/2022
NARRATIVE
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At 12:50PM, LPA observed vertical blinds were in disrepair. LPA observed items such as door mirror, recycling bottles, and old furniture was located in the backyard.

At 1:00PM, LPA observed side gate has an open lock on it. Administrator informed LPA that sometimes staff would lock it at night time to prevent people from coming inside. Staff removed lock during inspection.

At 1:05PM, LPA observed the RV in the backyard and a night staff was sleeping inside. Administrator informed LPA that the RV have been there for a couple years. Administrator stated that the staff sometimes use the storage room to rest and a bed was observed during visit. Administrator stated that the office in the garage was build a couple years ago too with permits. LPA requested a copy of the permits.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 8 of 8