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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200734
Report Date: 03/29/2024
Date Signed: 03/29/2024 05:49:29 PM

Document Has Been Signed on 03/29/2024 05:49 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JOY SENIOR CENTERFACILITY NUMBER:
019200734
ADMINISTRATOR:MATHARU, GURPREETFACILITY TYPE:
740
ADDRESS:6400 BRENTWOOD BLVDTELEPHONE:
(510) 543-4695
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 18CENSUS: DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Meledel Sumaylo CaregiverTIME COMPLETED:
06:00 PM
NARRATIVE
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On 03/29/2024 at 12:05PM, Licensing Program Analysts LPAs T.Syess-Gibson and L. Hall conducted an unannounced Annual 1-year required inspection. Caregiver Meledel Sumaylo contacted the Administrator by phone. LPAs toured the facility with caregiver Inoke Moa. Administrator, Gurpreet Matharu arrived at 2:00PM. The administrator currently holds a certificate (#6041833740) that expires on 08/15/2024. The facility’s fire clearance was approved for twelve (12) Non ambulatory and six (6) Bedridden residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of eleven (11) total bedrooms which Ten (10) bedrooms are occupied by the residents. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.5 degrees Fahrenheit. Night lights are maintained in hallways and passages to nonprivate bathrooms. Residents’ bathrooms are equipped with grab bars no non slip mats observed.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/08/2023. Emergency Disaster Plan was last posted on 11/18/2023. First aid kit was observed to be complete. Fire drill was last conducted on 11/03/2023.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
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: JOY SENIOR CENTER
FACILITY NUMBER: 019200734
VISIT DATE: 03/29/2024
NARRATIVE
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Continued from LIC809

The following deficiencies were observed:
  • At 12:30 PM LPAs observed all three (3) of the shared bathrooms did not have non skid mats.
  • At 12:32PM LPAs observed four (4) walkers, two(2) Wheel Chairs and one(1) Hoyer Lift located in the hallway blocking passageway.
  • At 12:36PM LPAs observed beds did not have mattress pads.
  • At 12:45PM LPAs observed there wasn't a Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days.
  • At 12:50PM LPAs observed refrigerator unsanitary.
  • At 12:55PM LPAs observed garbage inside of a grocery store basket on the side of the facility .
  • At 12:56 PM LPAs observed wooden planks from broken fence on ground obstructing walk path.
  • At 12:58PM LPAs observed Washer and Dryer on side of the facility blocking room number 2 exit.
  • At 2:25PM LPAs observed unlocked medicine cabinet containing resident medication.
  • At 4:45PM LPAs observed Medicine Administration Record was inaccurate.

Six (6) residents records were reviewed, current, and complete. Six (6) staff records were reviewed. LPAs also reviewed a sample of medication.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 04/05/2024:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
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: JOY SENIOR CENTER
FACILITY NUMBER: 019200734
VISIT DATE: 03/29/2024
NARRATIVE
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Continued from LIC809C
  • LIC 610E Emergency Disaster Plan (last page)
  • Residents roster
  • Updated facility sketch
  • Liability Insurance

Deficiencies cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy the appeal rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
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Document Has Been Signed on 03/29/2024 05:49 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/29/2024 at 04:55 PM
Link to Parent Document Below:
The Facility Number was changed to 079201440 After this Document was created!
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: JOY SENIOR CENTER
FACILITY NUMBER: 019200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 non skid mats in shared bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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2
3
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Administrator agreed to purchase non skid mats and submit photo to CCLD by POC date.
Type B
Section Cited
CCR
87307(3)(C)
3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in [having beds without mattress pads, top sheets, and blankets which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator agreed to place required linens on bed and submit self-certification that it has been completed 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 Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


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Document Has Been Signed on 03/29/2024 05:49 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/29/2024 at 05:03 PM
Link to Parent Document Below:
The Facility Number was changed to 079201440 After this Document was created!
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: JOY SENIOR CENTER
FACILITY NUMBER: 019200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care

(h) The following requirements shall apply to medications which are centrally stored:
(2) 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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Based on observation, the licensee did not comply with the section cited above in [having medication inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2024
Plan of Correction
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Caregiver immediately locked medication cabinet. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 03/29/2024 05:49 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/29/2024 at 05:07 PM
Link to Parent Document Below:
The Facility Number was changed to 079201440 After this Document was created!
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: JOY SENIOR CENTER
FACILITY NUMBER: 019200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)

87307 Personal Accommodations and Services

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building.

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 [using resident's bedroom to go to storage room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator agreed to move facility items out of storage in resident's bedroom and submit photo to CCLD by POC date.
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 indoor and outdoor passageways free of obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator agreed to remove all items and submit photos 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 Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2024 05:49 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/29/2024 at 05:11 PM
Link to Parent Document Below:
The Facility Number was changed to 079201440 After this Document was created!
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: JOY SENIOR CENTER
FACILITY NUMBER: 019200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(B)(26)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 not having 7-day non perishables and 2-day perishables available for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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Administrator agreed to purchase food and submit receipts and pictures of food to CCLD by POC date.
Type B
Section Cited
CCR
87465(d)(3)

87465 Incidental Medical and Dental Care
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:
(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation and record review, the licensee did not comply with the section cited above in the medication administrative record accurate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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2
3
4
Administrator agreed to submit self-certification that the MAR will be accurate for all residents going forward 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 Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2024 05:49 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/29/2024 at 05:16 PM
Link to Parent Document Below:
The Facility Number was changed to 079201440 After this Document was created!
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: JOY SENIOR CENTER
FACILITY NUMBER: 019200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) 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
1
2
3
4
Based on observation the licensee did not comply with the section cited above in having refrigerator in sanitary condition which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
Administrator agreed to clean refrigerator and submit photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
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