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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200657
Report Date: 07/30/2021
Date Signed: 07/30/2021 12:12:57 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:CMA CARE HOMEFACILITY NUMBER:
019200657
ADMINISTRATOR:CRUZ, IMELDA MFACILITY TYPE:
740
ADDRESS:42909 HAMILTON WAYTELEPHONE:
(510) 673-8038
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 5DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Imelda Cruz, AdministratorTIME COMPLETED:
12:25 PM
NARRATIVE
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On 7/30/2021 at 8:40AM, Licensing Program Analysts (LPAs) G. Luk and L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Imelda Cruz and explained the purpose of the visit.

Upon entry, staff checked LPAs temperature. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPAs observed sign & symptoms, hand washing posted in the common areas. Hand washing posters were posted at hand washing stations.

During record review, LPAs observed visitors log. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPEs, food, and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 9:05AM, LPAs observed unlocked scissors, knife, file, mallet, lighters, and gardening tools.
-At 9:15AM, LPAs observed unlocked medications in the garage.
-At 9:30AM, LPAs observed hallway bathroom next to the kitchen was unclean and side yard next to living room had ongoing repairs due to pumping issues. Concrete and dirt was removed and left unfinished.
-At 10:00AM, LPAs observed facility did not document resident observation notes since early 2021.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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 6
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: CMA CARE HOME
FACILITY NUMBER: 019200657
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 by having unlocked scissors, knives, mallet, and gardening tools which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/31/2021
Plan of Correction
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Administrator has locked up the scissors, knives, mallet, and gardening tool during inspection.

Deficiency cleared during inspection.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having unlocked medications in the garage which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/31/2021
Plan of Correction
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Administrator has locked up the medications during inspection.

Deficiency cleared during inspection.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: CMA CARE HOME
FACILITY NUMBER: 019200657
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not documenting resident's changes in condition which poses a potential health and safety risk to persons in care.
POC Due Date: 08/11/2021
Plan of Correction
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Administrator has agreed to conduct training for all staff regarding documenting resident's changes in condition on a regular basis and submit staff sign-in sheet to CCLD by POC date.
Type B
Section Cited
CCR
87303(a)
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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to uncleaned bathroom and unrepair sideyard pathway which poses a potential health and safety risk to persons in care.
POC Due Date: 08/11/2021
Plan of Correction
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Administrator has agreed to repair the sideyard pathway and submit picture as proof to CCLD by POC date.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2021
LIC809 (FAS) - (06/04)
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