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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601493
Report Date: 10/10/2022
Date Signed: 10/10/2022 01:35:01 PM


Document Has Been Signed on 10/10/2022 01:35 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:AGEWAY BOARDING CARE #3FACILITY NUMBER:
015601493
ADMINISTRATOR:DAYEH, ANAFACILITY TYPE:
740
ADDRESS:2636 NEVADA STREETTELEPHONE:
(510) 475-8869
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
10/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Miheal Dayeh, AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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On this day 10/10/22, Licensing Program Analyst (LPA) C. Lin conducted a case management visit and met with Administrator. LPA explained to him purpose of the visit.

During an investigation conducted by the Department, records obtained indicate that R1's pre-appraisal (LIC603) was not completed when admitting to facility on 3/1/2022. Administrator admitted it, agreed to have it complete, and keep it on file.

A deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.



Exit interview conducted with Administrator. A copy of this report and Appeal Rights was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
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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Document Has Been Signed on 10/10/2022 01:35 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: AGEWAY BOARDING CARE #3
FACILITY NUMBER: 015601493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2022
Section Cited

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87457 Pre-Admission Appraisal - General(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed.....

This requirement is not met as evidenced by…
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Based on record review, the licensee did not comply with the section cited above. LPA observed resident R1's pre-admission appraisal was not completed while admitting to facility on 3/1/22, which poses a potential health and safety concern to persons in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
LIC809 (FAS) - (06/04)
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