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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019200333
Report Date:
08/11/2023
Date Signed:
08/11/2023 03:35:03 PM
Document Has Been Signed on
08/11/2023 03:35 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 MANOR
FACILITY NUMBER:
019200333
ADMINISTRATOR:
GRACE R. ACOSTA
FACILITY TYPE:
735
ADDRESS:
36603 DEBORAH STREET
TELEPHONE:
(510) 739-1065
CITY:
NEWARK
STATE:
CA
ZIP CODE:
94560
CAPACITY:
6
CENSUS:
5
DATE:
08/11/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:45 AM
MET WITH:
Venice Ayala
TIME COMPLETED:
04:00 PM
NARRATIVE
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On this day at around 9:45 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Venice Ayala. LPA explained to Ayala the purpose of the visit. The facility is a Level 4C home vendored by the Regional Center of the East Bay (RCEB). Administrator Grace Acosta arrived at a later.
LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, kitchen, dining area, backyard and living area. There was sufficient lighting throughout the facility. No bodies of water were observed. There was sufficient supply of perishable and non-perishable foods. Sufficient blankets, sheets, towels, hand towels were observed. Fire extinguisher in the kitchen area was observed to be full and last inspected on 2/10/2023. Smoke detector and carbon monoxide were tested and observed operational.
Last fire and earthquake drills were conducted on 5/8/2023. At around 11:00 AM, LPA reviewed P&I money and log. The facility has sufficient amount of surety bond to cover amount of money being handled at one time. At 11:20 am, LPA reviewed 5 client files and 5 staff files. At around 2:20 pm, LPA interviewed 2 staff and 2 clients.
The following deficiencies were observed:
Two non ambulatory clients stay in ambulatory rooms
garage was converted to activity room
staff room was switched to client room
client has catheter but facility has no approved exception, no updated needs and services plan, no proof of staff training, no restricted condition health plan
continuation on Lic 809C
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/11/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/11/2023
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
6
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:
08/11/2023
NARRATIVE
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Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).
Exit interview was conducted and Appeal Rights was provided to the Administrator.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/11/2023
LIC809
(FAS) - (06/04)
Page:
6
of
6
Document Has Been Signed on
08/11/2023 03:35 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
08/11/2023
at
02:24 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:
08/11/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having 2 nonambulatory clients which poses an immediate health, safety or personal rights risk to persons in care. Facility does not have an approved fire clearance for nonambulatory.
POC Due Date:
08/12/2023
Plan of Correction
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4
Administrator will send to CCL request for nonambulatory fire clearance. Aministrator will notify local fire department regarding 2 nonambulatory clients and send CCL proof of notification.
Type A
Section Cited
CCR
80010(b)(1)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients. (1) Clients whose condition becomes nonambulatory shall not use rooms or areas restricted to ambulatory clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the facility did not comply with section above by having nonambulatory clients staying in ambulatory room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/12/2023
Plan of Correction
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4
Administrator states the facility will apply for 2 nonambulatory fire clearance in Rooms # 1 and #3 and submit request to CCL 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:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE:
08/11/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/11/2023
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
08/11/2023 03:35 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
08/11/2023
at
02:24 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:
08/11/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092(b)(4)
Restricted Health Conditions
(b) Care for the following health conditions must be provided only as specified in Sections 80092.1 through 80092.11. (4) Use of catheters only as specified in Section 80092.6.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in retaining a client with catheter without approved exception which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
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2
3
4
By POC date, Administrator will submit request for exception for client with catheter.
Type B
Section Cited
CCR
80092.1(g)
General Requirements for Restricted Health Conditions
(g) All new facility staff who will participate in meeting the client's specialized care needs shall complete the training prior to providing services to the client.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview, the licensee did not comply with the section cited above in not having needs and services plan updated with client's catheter which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
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By POC date, Administrator will submit updated needs and services plan addressing client's catheter.
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:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE:
08/11/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/11/2023
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
08/11/2023 03:35 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
08/11/2023
at
02:24 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:
08/11/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092.1(l)
General Requirements for Restricted Health Conditions
(l) All training shall be documented in the facility personnel files.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having proof of training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
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2
3
4
Administrator will submit to CCL proof of staff training by POC date.
Type B
Section Cited
CCR
80092.2(a)
Restricted Health Condition Care Plan
(a) If the licensee of an ARF chooses to care for a client with a restricted health condition, as specified in Section 80092, the licensee shall develop and maintain, as part of the Needs and Services Plan, a written Restricted Health Condition Care Plan. The plan must include all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on file review, the licensee did not comply with the section cited above in not having a restricted health condition care plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/18/2023
Plan of Correction
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3
4
By POC date, Administrator will submit restricted condition health plan for catheter.
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:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE:
08/11/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/11/2023
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
08/11/2023 03:35 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
08/11/2023
at
02:55 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:
08/11/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
Based on observation, the licensee did not comply with the section cited above in converting garage into an activity room and switching client/staff rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/12/2023
Plan of Correction
1
2
3
4
Administrator will submit updated facility sketch and request fire inspection by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE:
08/11/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/11/2023
LIC809
(FAS) - (06/04)
Page:
5
of
6