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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200403
Report Date: 12/27/2024
Date Signed: 01/03/2025 10:00:00 AM

Document Has Been Signed on 01/03/2025 10:00 AM - 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:FAYETH'S DOORFACILITY NUMBER:
019200403
ADMINISTRATOR/
DIRECTOR:		PAMELA BROWNFACILITY TYPE:
735
ADDRESS:1801 VIA BARRETTTELEPHONE:
(510) 385-8463
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY: 6CENSUS: 6DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Pamela BrownTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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On 01/03/2025 at 7:30 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Direct Care Staff, Margaret Ross who phoned the Administrator about the purpose of the visit. Administrator, Pamela Brown, arrived shortly after. Administrator certificate is current and expires on 06/09/2026. The facility’s fire clearance was approved for a capacity of six (6) ambulatory only.

There are 5 clients currently living at the facility. One client is in a skilled nursing facility.

LPAs toured the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 bedrooms and 2 bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing and bathing are safe, sanitary and in operating condition. There is sufficient supply of hygiene products available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/11/2024. Emergency Disaster Drill was last posted on 10/14/2024. First aid kit was observed to be complete. Fire drill was last conducted on 10/14/2024.

At 7:54 AM, 6 of clients records were reviewed. At 08:30 AM, 3 staff records were reviewed and 3 of 3 have current first aid training and are associated to the facility. LPAs reviewed client's P&I money with log and there was no discrepancies observed. LPAs reviewed clients' medications.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FAYETH'S DOOR
FACILITY NUMBER: 019200403
VISIT DATE: 12/27/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/10/2025:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan
Liability Insurance
Auto Insurance
Auto Registration

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 7:45 AM, LPA observed hot water measured in the kitchen at 131 degrees Fahrenheit and hot water measured at the shared bathroom at 129.4 degrees F.

The Facility was 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.

Exit interview was conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/03/2025 10:00 AM - It Cannot Be Edited


Created By: Patricia Manalo On 01/03/2025 at 09:45 AM
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: FAYETH'S DOOR
FACILITY NUMBER: 019200403

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 the hot water temperature measured at 131 degrees F in the kitchen sink and 129.4 degrees F in the shared bathroom which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/04/2025
Plan of Correction
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Administrator agrees to have the hot water temperature measured between 105 degrees F to 120 degrees F and send proof to CCLD by POC 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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
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