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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200544
Report Date: 02/15/2022
Date Signed: 02/15/2022 07:15:43 PM


Document Has Been Signed on 02/15/2022 07:15 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: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: 6DATE:
02/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Albert Leano/Administrator and
Leticia 'Lettie' Velasco/Staff		TIME COMPLETED:
07:25 PM
NARRATIVE
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While the facility conducting pre-licensing inspection for change in ownership, Licensing Program Analyst (LPA) Delmundo observed the following:
1. Central storage for medications and kitchen cabinet where knives are kept were unlocked.
2. Unlocked rubbing alcohol, Lysol spray, Windex, Hydrogen Peroxide, Raid Ant killer in the garage.
3. Tylenol, Vitamin C, scissors, other vitamins/supplements in unlocked staff room.
4. Ointments, peritoneal cleanser and razor in one of the resident's bedrooms.
5. Unlocked razor in the bathroom.
6. Bed frame, soiled collapsed box. piles of bricks in the backyard.
7. Hot water temperature at 141.9 degrees Fahrenheit.

Deficiencies are cited from Title 22 California Code of Regulations (see 809Ds). Failure to submit proof of corrections by plan of correction due dates may result in civil penaltiies.

Deficiencies and plan and proof of corrections were discussed with Albert Leano and Leticia Velasco.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided,
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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 3


Document Has Been Signed on 02/15/2022 07:15 PM - It Cannot Be Edited

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: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2022
Section Cited

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87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2)... Hot water temperature controls shall be maintained.... attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

Hot water temperature was tested and measured at 141.9 degrees Fahrenheit. Administrator adjusted the water heater gauge and hot water temperature was lowered to 106 degrees Fahrenheit.

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This requirement is not met as evidenced by:

-Based on observation, the licensee did not comply with the section above. Hot water temperature was measured at 141.9 degrees Fahrenheit which poses immediate safety risk to persons in care,
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Type A
02/16/2022
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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-Based on observation, the licensee did not comply with the section above. LPA observed unlocked kitchen cabinet where knives are kept which poses immediate safety 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: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/15/2022 07:15 PM - It Cannot Be Edited

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: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2022
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.



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LPA observed the following: unlocked rubbing alcohol, Lysol spray, Windex, Hydrogen Peroxide, Raid Ant killer in the garage; Tylenol, Vitamin C, scissors, other vitamins/supplements in unlocked staff room; Ointments, peritoneal cleanser and razor in one of the resident's bedrooms; Unlocked razor in the bathroom.
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Type B
02/22/2022
Section Cited

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87303 Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times.Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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-Based on observation, the licensee did not comply with the section cited above. LPA observed bed frame, soiled collapsed box. piles of bricks in the backyard. which pose potential safety risks 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: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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