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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200333
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:45:28 PM

Document Has Been Signed on 09/20/2024 02:45 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/
DIRECTOR:		GRACE R. ACOSTAFACILITY TYPE:
735
ADDRESS:36603 DEBORAH STREETTELEPHONE:
(510) 739-1065
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 6DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Venice AyalaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On this day at around 9:50 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with co Administrator 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 time.

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. Sufficient blankets, sheets, towels, hand towels were observed. Fire extinguisher in the kitchen area was observed to be full and last inspected on 2/6/2024. Smoke detector and carbon monoxide were tested and observed operational. The last fire drill was conducted on 9/14/2024.

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 10:50 am, LPA reviewed medications and Medications Administration Record (MAR) with Ayala. At 11:25 am, LPA reviewed 5 client files and 3 staff files. At around 1:25 pm, LPA interviewed 3 staff.

Deficiencies were cited under Title 22 California Code of Regulations (refer to Lic 809D). Civil penalty of $500.00 is assessed for today's visit.

Exit interview was conducted with the Administrator and Appeal Rights was provided.


SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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 09/20/2024 02:45 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 09/20/2024 at 02:12 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: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 chemicals, medicines unlocked and accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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The Administrator locked all chemicals and mdicines during the visit. This deficiency is cleared.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 measure at 123.8 Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Hot water was adjusted to 117 Fahrenheit during the visit. This deficiency is cleared.
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: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/20/2024 02:45 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 09/20/2024 at 02:12 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: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 dusty windows which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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By POC date, the Administrator will get all windows/blinds/screen dusted and submit photo proof to CCL.
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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/20/2024 02:45 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 09/20/2024 at 02:12 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: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

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 not having doctor's order for 2 clients OTC PRN medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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By POC date, the Administrator will submit to CCL a copy of doctor's order for the PRN medications.

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: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/20/2024 02:45 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 09/20/2024 at 02:13 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: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)


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 installing a lock in Room#3 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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During the visit, the Administrator had the lock removed. This deficiency is cleared. Civil penalty of $500 is assessed during the visit.
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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5