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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200199
Report Date: 10/18/2024
Date Signed: 10/18/2024 02:58:35 PM

Document Has Been Signed on 10/18/2024 02:58 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:FCSN EAST BAY ADULT DAY PROGRAMFACILITY NUMBER:
019200199
ADMINISTRATOR/
DIRECTOR:		AI-CHING "SYLVIA" YEHFACILITY TYPE:
775
ADDRESS:2300 PERALTA BLVD.TELEPHONE:
(510) 739-6900
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 105CENSUS: 19DATE:
10/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Vivian Largusa, Program Director TIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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On 10/18/2024 at 11:15 AM, Licensing Program Analysts (LPAs) P. Manalo and J. Clancy-Czuleger arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Program Director, Vivian Largusa, and explained the purpose of the visit.

LPA toured facility with Program Director including but not limited to, multiple activity rooms, kitchen, bathrooms, office space, and the outside recreational area. Clients bring their own lunches and snacks. Emergency supplies were observed. The hot water temperature in the client bathroom measured 116.3 degrees Fahrenheit. There are no bodies of water or fire safety hazards observed. Restrooms are maintained in safe and in sanitary operating condition, and additional equipment for the physically handicapped was observed.

At 12:45 PM, 6 of clients records were reviewed. At 1:35 PM, 4 staff records were reviewed and 4 of 4 have current first aid training and 4 of 4 associated to the facility. Fire extinguishers throughout facility were last inspected 02/14/2024. First aid kit was checked.

At 12:15 PM, LPAs observed Lock Dry Lubricant was found on the kitchen counter.

At 12:18 PM, LPAS observed twine and bowl filled with craft supplies was on top of the stove.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

The following forms to be updated and submitted to CCL by 10/25/2024:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 610 Emergency Disaster Plan

Exit interview conducted with Program Director. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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 10/18/2024 02:58 PM - It Cannot Be Edited


Created By: Patricia Manalo On 10/18/2024 at 02:01 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: FCSN EAST BAY ADULT DAY PROGRAM
FACILITY NUMBER: 019200199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 twine and a bowl filled with craft supplies on top of the stove which poses a potential health and safety risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Administrator agrees to remove the items from the top of the stove. POC cleared during the visit.
Type B
Section Cited
CCR
82076(a)(14)
Food Service
(a) In day programs providing meals to clients, the following shall apply: (14) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

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 unlocked Dry Lubricant on kitchen counter which poses a potential health and safety risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Administrator agrees to relocate the Dry Lubricant to a lock location. POC cleared during the visit.
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-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
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