015601481-1-7-2025-15-AS-PMAO-DCPRGQ-20250107120108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601481
Report Date: 01/07/2025
Date Signed: 01/07/2025 12:01:32 PM

Document Has Been Signed on 01/07/2025 12:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	COMMON DESTINY		FACILITY NUMBER:	015601481
ADMINISTRATOR/ DIRECTOR:	TOM, MARVIN		FACILITY TYPE:	740
ADDRESS:	34209 SYLVESTER DRIVE		TELEPHONE:	(510) 794-4931
CITY:	FREMONT	STATE: CA	ZIP CODE:	94555
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Leonora Maquilan, Care Staff		TIME VISIT/ INSPECTION COMPLETED:	12:15 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 01/07/2025 at 09:00AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Care Staff, Leonora Maquilan, and explained the purpose of the visit. Care Staff stated that the Licensee/ Administrator has been out of the country since 12/19/2024 and not available. LPAs toured facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which all 5 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature was measured at 110.7 degrees Fahrenheit. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 09/12/2024. First aid kit was observed to be complete. Staff does not have access to the staff and resident files. Files were not available for review during the visit. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/21/2025 LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate Infection Control Plan Continue to LIC809-C..

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMMON DESTINY	FACILITY NUMBER: 015601481
	VISIT DATE: 01/07/2025

NARRATIVE

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Continue from LIC 809..

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:10 AM, LPAs observed unlocked knives in the kitchen and unlocked insulin in the kitchen fridge accessible to residents.

At 9:05 AM, LPAs observed that all staff and resident files were not available during the visit.

At 9:15 AM, LPAs observed trash bags in the backyard and inside the garage that is not in the garbage bin due to an overflow.

At 9:17 AM, LPAs observed the left side gate with a paddle lock. Staff admits that they lock the gate at night. Civil penalty of $500 is being assessed.

At 9:20 AM, LPAs observed washing machine, stove, wheelchair, shower chair, RV, etc in the backyard.

At 10:00 AM, LPAs observed R3 is on insulin sliding scale and unable to determine amount of insulin needed due to poor vision.

At 10:15 AM, LPAs observed the Medication Administration Record not having an accurate record of dosages of medications

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with care staff. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia Manalo	TELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/07/2025 12:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMMON DESTINY	FACILITY NUMBER: 015601481
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a paddle lock in the side gate which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/08/2025
	Plan of Correction
1 2 3 4	Staff agrees to remove the paddle lock from the gate and send proof to CCLD by POC date. Civil Penalty of $500 is assessed.

Section Cited

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 in having unlocked knives in the kitchen drawer and unlocked insulin in the kitchen fridge which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/08/2025
	Plan of Correction
1 2 3 4	Staff agrees to remove the items and placed it in a lock storage and send proof 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.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/07/2025 12:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMMON DESTINY	FACILITY NUMBER: 015601481
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Diabetes

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview conducted with R3 who is diabetic and on sliding scale of insulin, R3 states that R3 is unable to see how much insulin is needed due to very poor vision. R3 states staff twists the pen for the correct dose of insulin and guides hand to the stomach and R3 presses pen. The facility doe snot have an approved exception for R3.
	POC Due Date: 01/21/2025
	Plan of Correction
1 2 3 4	By POC date, the Administrator will send CCL plan on R3's restricted condition.

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.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document Has Been Signed on 01/07/2025 12:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMMON DESTINY	FACILITY NUMBER: 015601481
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Infection Control Requirements

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission. 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 by having trash bags in the backyard and in the garage, and not in the trash bin poses a potential health and safety risk to persons in care.
	POC Due Date: 01/21/2025
	Plan of Correction
1 2 3 4	Administrator agrees to remove the trash bags and obtain a bigger trash bin and send proof to CCLD by POC date.

Section Cited

Maintenance and Operation

(a) 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a washing machine, stove, wheelchair, shower chair, RV, etc. in the backyard which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/21/2025
	Plan of Correction
1 2 3 4	Administrator agrees to remove the items and send proof 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.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/07/2025 12:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMMON DESTINY	FACILITY NUMBER: 015601481
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 by not having the staff files available during the annual visit which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/21/2025
	Plan of Correction
1 2 3 4	The Administrator will to self certify to give access to the designated person of all the records when Administrator is on leave and send proof to CCLD of the POC.

Section Cited

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and file review, the licensee did not comply with the section cited above in not having an accurate record of dosages of medications which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	BY POC date, the Administrator will review MARs and doctor's order for all residents' medications and submit corrected copy to CCL.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

Page: 5 of 9

Document Has Been Signed on 01/07/2025 12:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMMON DESTINY	FACILITY NUMBER: 015601481
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Resident Records

(b) Each resident's record shall contain at least the following information: 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 by not having the resident files available during the annual visit which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/21/2025
	Plan of Correction
1 2 3 4	The Administrator will to self certify to give access to the designated person of all the records when Administrator is on leave and send proof to CCLD of the POC.

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.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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