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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200444
Report Date: 02/21/2025
Date Signed: 02/21/2025 03:34:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/21/2025 03:34 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:WAY OF THE ELDERSFACILITY NUMBER:
019200444
ADMINISTRATOR/
DIRECTOR:		SISTER MARYGRACE PUCHACFACILITY TYPE:
775
ADDRESS:2700-A MERCED STREETTELEPHONE:
(510) 352-1867
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 40CENSUS: 26DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Sister Mary GraceTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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At around 11 am, LPA Luisa Fontanilla arrived unannounced to conduct annual required inspection and met with Team Lead Brian Jimenez. LPA explained to Jimenez the purpose of the visit. Executive Director Sister Mary Grace arrived at a later time. She authorized Jimenez to sign the report.

This adult day program (ADP) has moved temporarily from the original location to 797 Montague Avenue, San Leandro 94577. The ADP currently shares building with Evergreen Day Program, another ADP operated by the same Licensee. Based on interviews conducted by LPA with the Executive Director and Program Director, the ADP's new location will be at 14826 Wicks Blvd San Leandro. However, the building is not yet approved by the city and is still in the process of installing sprinklers.

LPA verified with Evergreen Program census which is 62. The Evergreen Program is approved for 150 capacity. Clients use the same entrance/exit. The lobby including the kitchen has been assigned to the Way of the Elders clients. Bathrooms are shared by both programs. Each program has its own staff.

LPA inspected the areas occupied by this ADP as well as the shared common areas. There are 2 toilets, 1 for men and 1 for women with 3 stalls each. There is a changing room designated for Elders Way clients only. There are 26 clients and 13 staff observed during the visit. The ADP does not provide meals. However, there are foods available in the kitchen in case a client does not have food.

continuation on Lic 809C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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: WAY OF THE ELDERS
FACILITY NUMBER: 019200444
VISIT DATE: 02/21/2025
NARRATIVE
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At around 12:50 pm, LPA reviewed 5 client files and 7 staff files. All staff are fingerprint cleared and associated to the facility.

Last fire drill was conducted on 1/10/2025. Fire extinguishers appeared full and were last serviced on 10/30/2024. Hot water measured at 107.6 Fahrenheit.

Type A and B deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Jimenez and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/21/2025 03:34 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/21/2025 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: WAY OF THE ELDERS
FACILITY NUMBER: 019200444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2025
Section Cited
CCR
82075(f)

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82075(f) Health-Related Services Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation from persons qualified by agencies including, but not limited to, the American Red Cross.

This requirement is not met as evidenced by:
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By POC date, ADP will submit staff current First/CPR proof of training to CCL.
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Based on record reviews conducted, all DSP on shift have expired First aid/CPR training which poses an immediate health and safety risk to clients under care.
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Type B
02/24/2025
Section Cited
CCR82034

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82034 Submission of New Application
(a) A licensee shall file a new application as required by Section 82018(d) whenever there is a change in conditions or limitations described on the current license, or other changes including, but not limited to, the following:
(1) Any change in the location of the day program.
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By Monday, 2/24/2025, Executive Director states that a new application will be submitted to CAB and will notify CCL.
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This requirement is not met as evidenced by: The ADP changed location effective January 2, 2025 without submitting a new application which poses an immediate risk to the health and safety of clients under care.
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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: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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