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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601493
Report Date: 04/24/2024
Date Signed: 04/24/2024 01:37:02 PM


Document Has Been Signed on 04/24/2024 01:37 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: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:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mihael Dayeh/Marina VelasquezTIME COMPLETED:
02:05 PM
NARRATIVE
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At around 10 am, Licensing Program Analyst (LPA) arrived unannounced to conduct annual required inspection. LPA met with staff Marina Velasquez and explained the purpose of visit. Administrator Mihael Dayeh arrived at a later time. Mihael authorized staff Marina to sign reports.

The facility has 4 residents and 3 staff observed during the visit. LPA inspected the facility inside and out including but not limited to resident rooms, bathrooms, dining area, garage and backyard. Chemicals were locked in the garage. Knives and other sharp objects were locked in a drawer in the kitchen. There was sufficient supply of perishable and non perishable foods. Smoke detectors and carbon monoxide were tested and observed functional. The facility temperature was observed at 71 F. There were several fire extinguishers observed that appeared full and last serviced on 1/15/2024.

Administrator provided LPA updated liability insurance, Resident Roster, Lic 500.

At 10:05 am, LPA observed hot water in the kitchen measured at 127.6 F.

At 10:55 am, LPA interviewed 3 residents. At 11:05 am, LPA reviewed 4 resident files and 4 staff files. All staff are fingerprint cleared and associated to the facility. They have current First aid/CPR training. At 12:10pm, LPA interviewed 2 staff.


Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted and Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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 04/24/2024 01:37 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: AGEWAY BOARDING CARE #3

FACILITY NUMBER: 015601493

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


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 in having hot water measuring at 126.7 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
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Hot water was adjusted to 109 F during the visit. This deficiency is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
LIC809 (FAS) - (06/04)
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