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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200808
Report Date: 01/05/2022
Date Signed: 01/05/2022 05:26:38 PM

Document Has Been Signed on 01/05/2022 05:26 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:DOORSFACILITY NUMBER:
019200808
ADMINISTRATOR:ERIC UMALIFACILITY TYPE:
735
ADDRESS:1043 GILBERT STREETTELEPHONE:
(510) 363-8294
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 4CENSUS: 4DATE:
01/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Eric Umali/AdministratorTIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Eric Domulot, staff. LPA requested Domulot to call Eric Umali, administrator, who arrived after about 15 minutes. LPA informed the purpose of visit. LPA also met with other staff, Elaine Rivera, Jessica Amenaghawon (S2) and staff (S1).

Facility has an approved LIC808 COVID-19 Mitigation Plan.

LPA inspected the facility inside and out with Eric Umali. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, surgical masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and visitors. Residents body temperature are also checked and recorded daily. Trash bins were observed with pedal operated lids.

Medications are centrally stored in the a locked cabinet. Centrally stored PPEs inspected. There were at least 7 days of nonperishable and 2 days of perishable food supplies.

Fire extinguisher was observed fully charge and tag showed serviced May 21, 2021. Smoke and carbon monoxide detectors were operational. First aid kit inspected and observed complete with manual.

LPA observed the following:
1. Disposable gowns not sufficient for 30 days for 9 staff. Facility only has 60 disposable gowns on hand.
2. Jessica Amenaghawon is finger print cleared but not associated to this facility.
3. Staff (S1) who needed exemption has been working for 2 days. LPA verified with Eric Umali and confirmed with S1 that S1 started working January 3, 2022 and today, January 5, 2022.
.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2022
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 5
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: DOORS
FACILITY NUMBER: 019200808
VISIT DATE: 01/05/2022
NARRATIVE
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LPA verified and Eric Umali stated all staff were fit tested for N95 respirator, however, the facility does not have record. Copy of fit testing record to be submitted by January 19, 2022.

LPA requested for copies of the following updated documents to be submitted by January 19, 2022:
1. LIC500 Personnel Report
2. LIC308 Designation of Facility Responsibility
3. LIC610D Emergency Disaster Plan

Deficiencies are cited from Title 22 California Code of Regulations (see 809Ds). A $200.00 civil penalty is assessed for section 80019(e)(3). Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiencies and plan of corrections were discussed with Ebony Omelagah (licensee) over the phone in the presence of Eric Umali.

Exit interview conducted. Appeal Rights, LIC421BG Civil Penalty, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/05/2022 05:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/05/2022 at 04:40 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: DOORS
FACILITY NUMBER: 019200808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and review of the Department's fingerprint clearance record, the licensee did not comply with the section cited above for having staff (S1) work prior to requesting and having exemption approved which poses an immediate safety risk to persons in care.
A $200.00 civil penalty is assessed.
POC Due Date: 01/06/2022
Plan of Correction
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S1 left while LPA is at the facility.
Licensee stated she'll submit exemption request. Copy of documents to be submitted by January 6, 2022 along with a self-certification that S1 will not be allowed to work until exemption is completely processed and S1 is associated.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/05/2022 05:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/05/2022 at 04:56 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: DOORS
FACILITY NUMBER: 019200808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(i)(2)
80065 Personnel Requirements
(i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(2) Request a transfer of a criminal record clearance as specified in Section 80019(f)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for not having staff's (S2) criminal record clearance properly transferred to this facility which poses a potential safety risk to persons in care.
POC Due Date: 01/19/2022
Plan of Correction
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Corrected.
Licensee processed the transfer on this same day, 1/05/2022.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2022


LIC809 (FAS) - (06/04)
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