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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200658
Report Date: 12/23/2024
Date Signed: 12/23/2024 11:31:16 AM

Document Has Been Signed on 12/23/2024 11:31 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:EVELYN MANORFACILITY NUMBER:
019200658
ADMINISTRATOR/
DIRECTOR:		MONTECLAR, IRENEFACILITY TYPE:
735
ADDRESS:1076 TULANE AVETELEPHONE:
(510) 878-2352
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY: 4CENSUS: 4DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Irene Monteclar, Administrator TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 12/23/2024 at 09:00 AM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Care Staff, Charito Aberle, who phoned the Administrator and explained the purpose of the visit. Administrator, Irene Monteclar, came shortly after. Administrator certificate is current and expires on 06/25/2025. The facility’s fire clearance was approved for a capacity of four (4) of which two (2) may be non-ambulatory.

LPAs toured the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms and 1 office which all 4 bedrooms are occupied by the clients. There are no bodies of water. A comfortable temperature for clients is maintained at 76 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 131.1 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishables and 2-day perishables food supply. Centrally stored medication and sharps were locked and inaccessible to clients.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 07/24/2024. Emergency Disaster Drill was last posted on 12/23/2024. First aid kit was observed to be complete. Fire drill was last conducted on 12/02/2024.

At 9:15 AM, 4 of clients records were reviewed. At 9:36 AM, 5 staff records were reviewed and 5 of 5 have current first aid training and 5 of 5 associated to the facility. At 9:45 AM, LPAs reviewed client's P&I money with log and there was no discrepancies observed. At 10:00 AM, LPAs reviewed clients' medications. All records were observed to be complete.

Continue from LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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: EVELYN MANOR
FACILITY NUMBER: 019200658
VISIT DATE: 12/23/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 01/03/2025:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan
Liability Insurance
Auto Insurance
Driver's License

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:10 AM, LPAs observed black mold in the kitchen sink.

At 9:12 AM, LPAs observed unlocked cleaning chemicals under the kitchen sink.

At 9:15 AM, LPAs observed hot water temperature measured at 131.1 degrees Fahrenheit.

At 9:17 AM, LPAs observed broken screen door in bedroom #2.

At 9:30 AM, LPAs observed both facility side gates were locked. Civil penalty of $500 is being assessed.


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 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: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/23/2024 11:31 AM - It Cannot Be Edited


Created By: Patricia Manalo On 12/23/2024 at 10:54 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: EVELYN MANOR
FACILITY NUMBER: 019200658

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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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4
Based on observation, the licensee did not comply with the section cited above in having unlocked cleaning chemicals under the sink which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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2
3
4
Staff locked the chemicals under the sink during the visit. Deficiency cleared.
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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4
Based on observation, the licensee did not comply with the section cited above in having the hot water temperature measured at 131.1 which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Staff corrected deficiency during visit and hot water was measured at 106.8. Deficiency cleared.
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: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/23/2024 11:31 AM - It Cannot Be Edited


Created By: Patricia Manalo On 12/23/2024 at 10:54 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: EVELYN MANOR
FACILITY NUMBER: 019200658

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above by locking both side gates without fire clearance for locked parameter which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Staff removed locks during inspection. Deficiency cleared.

Civil penalty of $500 is being assessed.
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: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/23/2024 11:31 AM - It Cannot Be Edited


Created By: Patricia Manalo On 12/23/2024 at 10:54 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: EVELYN MANOR
FACILITY NUMBER: 019200658

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, 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 in having black mold in the kitchen sink and broken screen door in bedroom #2 which poses a potential health and safety risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Administrator agrees to replace the sink to remove the black mold and replace the broken screen door and send proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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3
4
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: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6