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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200141
Report Date: 01/25/2024
Date Signed: 01/25/2024 05:53:13 PM

Document Has Been Signed on 01/25/2024 05:53 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:PARKWAY VILLAGE CARE HOME, INC.FACILITY NUMBER:
019200141
ADMINISTRATOR:JACQUELINE SANTOSFACILITY TYPE:
735
ADDRESS:183 HERMES COURTTELEPHONE:
(510) 586-0547
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jacqueline Santos, AdministratorTIME COMPLETED:
06:05 PM
NARRATIVE
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On 1/25/2024 at 1:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Jacqueline Santos and explained the purpose of the visit. The facility’s fire clearance was approved for 6 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, shed, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 2/2/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 109.4 degrees F in the hallway bathroom sink. There were adequate lights in each room. First Aid kit is complete. Last fire drill was conducted on 1/26/2024.

LPA reviewed 3 client and 3 staff files starting at 2:30PM. LPA reviewed a sample of client's medications starting at 4:25PM. LPA interviewed 2 clients and 2 staff at 4:40PM.

At 2:00PM, LPA observed the shed in the backyard has a bed and was informed by administrator that S2 has been sleeping in the shed.

At 3:00PM, LPA observed C1 and C3 does not have current appraisals on file.

At 3:10PM, LPA observed all clients does not have functional capability assessment completed.

(Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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 5
Document Has Been Signed on 01/25/2024 05:53 PM - It Cannot Be Edited


Created By: Grace Luk On 01/25/2024 at 05:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PARKWAY VILLAGE CARE HOME, INC.
FACILITY NUMBER: 019200141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)(A)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings.

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 by having a staff sleep in the shed which poses a potential health and safety risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator has agreed to create a plan to address staff sleeping in the shed which has not been approved by fire department. Administrator will submit the plan to CCLD by POC date.
Type B
Section Cited
CCR
80069.2(b)
Functional Capabilities Assessment
(b) Assessment of the client's need for assistance shall include consideration of his/her physical condition affecting participation in his/her own care, including:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having functional capability assessment completed which poses a potential health and safety risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator has agreed to complete functional capability assessment for all clients and send copies 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PARKWAY VILLAGE CARE HOME, INC.
FACILITY NUMBER: 019200141
VISIT DATE: 01/25/2024
NARRATIVE
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At 3:30PM, LPA observed S3 does not have health screening and TB test completed. S3 has been working at the facility for over a week.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/25/2024 05:53 PM - It Cannot Be Edited


Created By: Grace Luk On 01/25/2024 at 05:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PARKWAY VILLAGE CARE HOME, INC.
FACILITY NUMBER: 019200141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.2(b)(1)
(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:
(1) The needs appraisal or IPP is not more than one year old.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current appraisals for two clients which poses a potential health and safety risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator has agreed to obtain current appraisals for C1 and C3 and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
80065(g)(1)
(g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having health screening and TB test for S3 which poses a potential health and safety risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator has agreed to obtain health screening and TB test for S3 and submit a copy 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
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