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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601493
Report Date: 01/26/2023
Date Signed: 01/26/2023 04:14:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221006145937
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
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Marina Velasquez, Lead CaregiverTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff do not meet resident's hygiene needs.
INVESTIGATION FINDINGS:
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On 1/26/23 at 9:45am, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegation and deliver investigation findings. LPA met with staff and explained the purpose of the visit. Administrator was unable to come and have phone conversation with LPA.

The Department has investigated this allegation and per observation and found that staff S2 didn’t dispose gloves after assisting resident’s toileting, continued assisting resident for getting a cup of water, putting up a blanket, and straightening resident’s clothes with the same pair of gloves during the investigation visit.
Based on information obtained, the preponderance of evidence is met, therefore the allegations are SUBSTANTIATED.

Continue LIC9099-C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20221006145937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/26/2023
NARRATIVE
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Deficiency is cited from Title 22 California Code of Regulations and Health and Safety Code (see 9099D). 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.

Deficiency and plan and proof of correction were discussed with on-duty staff and Administrator over the phone. Exit interview conducted. Appeal Rights, LIC9099D, and copy this report 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221006145937

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
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Marina Velasquez, Lead CaregiverTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident sustained multiple stage 2 ulcers in care due to staff neglect.
Facility staff yell at resident.
INVESTIGATION FINDINGS:
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On 1/26/23 at 9:45am, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegation and deliver investigation findings. LPA met with staff and explained the purpose of the visit.

Allegation: Resident sustained multiple stage 2 ulcers in care due to staff neglect - Unsubstantiated
The Department has investigated this allegation and per records review and interviews, found staff chaged and cleaned resident regularly, bathed resident daily. When staff noticed resident developed pressure ulcers in March and June 2022, facility staff informed R1’s representative, and the representative notified R1’s physician and had home health nurse visit resident and take care of the wound.

Continue LIC9099A-C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20221006145937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/26/2023
NARRATIVE
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Allegation: Facility staff yell at resident - Unsubstantiated
The Department has investigated this allegation and per records review and interviews, found that staff denied the alleged violation, both residents R2 and R3 stated that all staff were very nice, they have not witnessed any staff member yelled at resident. No other witness was found.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

No deficiency cited. Exit interview conducted with staff and a copy of this report 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20221006145937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87470(a)(1)(B)
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87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: (1) All staff and volunteers shall perform hand hygiene. (B) Hand hygiene shall be conducted as follows:
This requirement is not met as evidenced by…
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Administrator agrees to review regulation, retrain staff, 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 dispose gloves after assisting resident for toileting and continued to perform other tasks with the same pair of gloves 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5