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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200659
Report Date: 02/22/2024
Date Signed: 02/22/2024 02:17:34 PM

Document Has Been Signed on 02/22/2024 02:17 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:DEAF PLUS ADULT COMMUNITYFACILITY NUMBER:
019200659
ADMINISTRATOR:NOLD, TERESAFACILITY TYPE:
775
ADDRESS:5437 CENTRAL AVE 4TELEPHONE:
(510) 556-2755
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 30CENSUS: 22DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Teresa NoldTIME COMPLETED:
02:40 PM
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On this day at around 10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA met with Program Administrator Teresa Nold and explained the purpose of the visit. ASL Interpreter Ari Lathuras was present during the visit.

During the visit, LPA inspected the facility inside and out including but not limited to common areas, bathrooms, kitchen and separate room for ill clients. Hot water measured at 115 degrees Fahrenheit in one of the bathrooms. The day program does not provide food to the clients but have back up food supplies, if needed. Chemicals were observed locked. Smoke detectors and carbon monoxide were tested and observed operational. There a fire extinguishers observed that appeared full and were last serviced on 11/16/2023. The last fire drill was conducted in December 2023.

LPA with the assistance of interpreter Ari Lathuras interviewed two clients and two staff. LPA reviewed five client and five staff files.

The following deficiencies were observed:
  • S4 and S5 do not have proof of First aid/CPR training on file
  • S1 does not have health screening on file
  • S3 does not have health screening on file

Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D). Failure to submit proof of corrections (POCs) by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.
Exit interview was conducted. Appeal Rights and a copy of this report were provided to Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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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Document Has Been Signed on 02/22/2024 02:17 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/22/2024 at 01:58 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: DEAF PLUS ADULT COMMUNITY
FACILITY NUMBER: 019200659

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82066(b)(1)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following information: (1) A health statement as specified in Section 82065(g)(1)(B).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review conducted, the licensee did not comply with the section cited above in having 2 staff without health screening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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2
3
4
By POC date, Administrator will send proof of health screening for S1 and S3.
Type A
Section Cited
CCR
82075(f)
Health-Related Services
(f) 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:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in having 2 staff without current First Aid/CPR training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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2
3
4
By POC date, Administrator will submit proof of First aid/CPR training for S4 and S5.
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: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
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