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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200333
Report Date: 10/27/2022
Date Signed: 10/27/2022 03:41:29 PM

Document Has Been Signed on 10/27/2022 03:41 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:SAI NEWARK MANORFACILITY NUMBER:
019200333
ADMINISTRATOR:GRACE R. ACOSTAFACILITY TYPE:
735
ADDRESS:36603 DEBORAH STREETTELEPHONE:
(510) 739-1065
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 6DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Care Staff, Jocelyn AcostaTIME COMPLETED:
03:50 PM
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On 10/27/2022, at 2:06 PM, Licensing Program Analyst (LPA) Liridon Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by Jocelyn Acosta, Care Staff, at front door entrance. Licensee is giving consent to care staff to tour and sign report on her behave.

During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All sharps and toxins were locked up and inaccessible to clients in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at _ degrees F. Fire extinguisher was last serviced on 2/24/2022. Facilities room temperature is maintained at 73 Degrees F. First aid kit is complete. Carbon monoxide and smoke detector are operable. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care.

During record review, LPA observed facility has a copy of their Infection Control Plan.



Continue on Lic809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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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: SAI NEWARK MANOR
FACILITY NUMBER: 019200333
VISIT DATE: 10/27/2022
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Continued on Lic809-C

The following Deficiency was observed during visit:

At 2:26 PM, LPA observed Administrator is not finger print cleared. Administrator has been in the facility since October 1, 2021. LPA asked Administrator to leave the premises and to return to facility once fingerprints are cleared

A civil penalty is being assessed for the amount of $500.00 for todays visit.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.



Exit interview conducted with Care Staff, appeal rights provided along with this report.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2022 03:41 PM - It Cannot Be Edited


Created By: Liridon Fici On 10/27/2022 at 03:23 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: SAI NEWARK MANOR
FACILITY NUMBER: 019200333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by allowing Administrator to work in the facility with no finger print clearance since October 1, 2021, which poses a potential health and safety risk to persons in care.
POC Due Date: 11/03/2022
Plan of Correction
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Licensee agreed to submit proper documents to CCL to obtain finger print clearance for Administrator to work in the facility by POC due date.
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-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022


LIC809 (FAS) - (06/04)
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