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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200807
Report Date: 11/29/2023
Date Signed: 11/29/2023 02:14:56 PM


Document Has Been Signed on 11/29/2023 02:14 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:CONTINUANCE CARE HOME LLCFACILITY NUMBER:
019200807
ADMINISTRATOR:MARSHALL, SHIRLEYFACILITY TYPE:
740
ADDRESS:565 SCHAFER RDTELEPHONE:
(510) 398-8994
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:16CENSUS: 15DATE:
11/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mandar Kulkarni TIME COMPLETED:
02:30 PM
NARRATIVE
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On 11/29/23 at 09:15 am Licensing Program Analyst (LPA) J. Clancy-Czuleger conduct a case management visit. LPA met with Staff member Wyrek Fagin and explained the reason for the visit. Administrator Sherley Marshall was called to be informed but was unable to come to the facility and Licensee Mandar Kulkarni was called and joined later.

While at the facility to deliver findings for a complaint investigation (15-AS-20230522092645), LPA observed the following;


  • Medication unlocked
  • Laundry soap and cleaning supplies unlocked
  • Lighter accessible to residents
  • Expired fire extinguisher
  • Smell of urine in room 7, and Urine left in bathroom toilet.
  • Emergency food supply
  • Sticky cabinets and drawers in kitchen
  • Fruit flies in dining area
  • Water damage under the kitchen sink


The deficiency were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in 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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
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 11/29/2023 02:14 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: CONTINUANCE CARE HOME LLC
FACILITY NUMBER: 019200807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87705(f)(2)

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(f) The following shall be stored inaccessible to residents with dementia:(2)Over-the-counter medication...cleaning supplies and disinfectants.This requirement was not met and evidenced by:
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The facility agrees to lock up the medication and do a training with all staff covering medications storage by POC date. Proof of training will be sent to CCL.
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LPA observed the medication cabinet in the hall left open and accessible
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Type A
12/01/2023
Section Cited
CCR87309(a)(1)

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(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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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The facility agrees to lock up the laundry soap and cleaning supplies do a training with all staff covering proper storage of chemicals and cleaning supplies by POC date. Proof of training will be sent to CCL.
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This requirement was not met and evidenced by: LPA observed cleaning supplies and laundry soap unlocked
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 11/29/2023 02:14 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: CONTINUANCE CARE HOME LLC
FACILITY NUMBER: 019200807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
CCR
87203

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met and evidenced by:
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 The facility agrees to replace or have the fire extingushers services by POC date. Proof of training will be sent to CCL.
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LPA observed expired fire extinguisher tags on all three extinguisher
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Type B
12/06/2023
Section Cited
CCR87303(a)(1)

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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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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 The facility agrees to clean room 7 and the bathrooms by POC date. Proof of training will be sent to CCL.
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This requirement was not met and evidenced by: LPA observed the smell of urine in room 7 and urine left in the toliet in one of the bathrooms
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 11/29/2023 02:14 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: CONTINUANCE CARE HOME LLC
FACILITY NUMBER: 019200807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
CCR
87555(b)(26)

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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 was not met and evidenced by:
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 The facility agrees to purchase additional nonperishable food by POC date. Proof of training will be sent to CCL.
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LPA observed that the facility did not have an adequate food supply of one week of nonperishable and two days of perishable foods for 15 residents.
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Type B
12/13/2023
Section Cited
CCR87303(a)

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(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 was not met and evidenced by:
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 The facility agrees to clean the kitchen cabinets,schedule a pest company to come out and to repair the water damage under the kitchen sink by POC date. Proof of training will be sent to CCL.
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LPA observed flies flying around in the dining room, sticky cabinets in the kitchen and water damage under the kitchen sink.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5