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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601493
Report Date: 01/26/2023
Date Signed: 01/26/2023 04:17:20 PM


Document Has Been Signed on 01/26/2023 04:17 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: 4DATE:
01/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Marina Velasquez, Lead CaregiverTIME COMPLETED:
04:30 PM
NARRATIVE
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On 1/26/23 at 2:40 p.m., Licensing Program Analyst (LPA) Catherine Lin conducted case management, met with staff, and explained the purpose of visit.

During the course of investigation on a complaint, the Department observed the following deficiencies.

· Staff did not update needs & service plan (LIC625) when R1's health condition was changed.

· Staff did not have care note for resident health condition change.

Deficiencies are cited per Title 22 California Code of Regulations. Please refer to LIC 809D.Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Exit interview conducted with staff and Administrator over the phone, Appeal Rights and a copy of this report were provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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 2


Document Has Been Signed on 01/26/2023 04:17 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: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2023
Section Cited

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87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate….

This requirement is not met as evidenced by…
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Administrator agrees to review and understand regulation and submit a self-certification of being in compliance in future events to CCL by the POC due date.
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Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t reappraise resident when resident have pressure ulcers multiple times which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/02/2023
Section Cited

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87506 Resident Records
(b) Each resident’s record shall contain at least the following information:
(13) Continuing record of any illness, injury....impacts the resident's ability to function or needed services.
This requirement is not met as evidenced by…
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Administrator agrees to review and understand regulation, retrain staff for note taking, and submit in-service training with staff signatures to CCL by the POC due date.
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Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t have care note for resident who have health condition change which poses/posed a potential health, safety or personal rights risk 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: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2