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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200544
Report Date: 05/05/2021
Date Signed: 05/05/2021 04:18:40 PM

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:AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
019200544
ADMINISTRATOR:ALBERT LEANOFACILITY TYPE:
740
ADDRESS:23652 NEVADA ROADTELEPHONE:
(510) 314-0807
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 4DATE:
05/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Helen Macatangay/LicenseeTIME COMPLETED:
01:00 PM
NARRATIVE
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During investigation of the complaint (15-AS-20201125165732), Licensing Program Analyst (LPA) Delmundo obtained information and learned that resident (R2) was denied access to facility land line phone. Staff (S2 and S3) indicated they give the phone to R2 if she’s going to call family members. They don’t give the land line phone if R2 is going to call other than family members.

On this day, May 5, 2021, LPA Delmundo called and spoke with Helen Macatangay, licensee, and informed of the above. LPA further informed that due to Shelter in Place Order by the Governor and management directive to telework, LPA is conducting this case management via televisit.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty.

Exit interview conducted. Copy of this report, Appeal Rights and LIC9098 Proof of Correction form provided via e-mail.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
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: AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 019200544
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls.
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-This requirement is not met as evidenced by:

-Based on interviews, licensee did not comply with the Regulation when staff denied R2 use of facility telephone which poses potential rights risk to persons in 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2021
LIC809 (FAS) - (06/04)
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