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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200808
Report Date: 01/18/2024
Date Signed: 01/18/2024 06:51:19 PM

Document Has Been Signed on 01/18/2024 06:51 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:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Eric Umali/AdministratorTIME COMPLETED:
06:55 PM
NARRATIVE
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On this day, January 18, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Lucky Amenaghawon and Elaine Rivera, and informed the reason for visit. LPA called and left message on Eric Umali's (administrator) voice mail.
Administrator arrived at around 12:30 p.m.

Administrator submitted the facility's Infection Control Plan which LPA received on June 30, 2022.

LPA conducted inspection with Elaine Rivera. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and storage for cleaning supplies were observed locked.

Facility has 2 in 1 smoke and carbon monoxide detector that was tested, and observed functional. Facility conducts emergency and fire drills at least every quarter, and records showed last conducted November 11. 2023 and December 13. 2023 respectively. Fire extinguisher checked, observed fully charge with tag showed serviced May 5, 2023. Hot water temperature in the bathroom was tested and measured at 111 degrees Fahrenheit.

LPA reviewed 3 staff and 4 resident records, and interviewed 2 staff and 2 residents. Medications were checked and compared with doctor's orders on file and LIC622 Centrally Stored Medication and Destruction Records. Residents' P&I were checked and compared with records.


...continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DOORS
FACILITY NUMBER: 019200808
VISIT DATE: 01/18/2024
NARRATIVE
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LPA received the following updated/current documents:
1. LIC308 Designation of Facility Responsibility
2. LIC610D Emergency Disaster Plan (9 pages)
3. Proof of Surety Bond coverage

Administrator to submit a copy of updated LIC500 Personnel Report by February 1, 2024.

LPA observed the following:
-a 12:24 p.m. to 12:26 p.m., door, pieces of wood, piece of gutter, chair frame, broken Foos ball table. rusted chairs in the side yard.
-at 2:15 p.m., staff (S2) does not have LIC501 Personnel Record on file.
-at 2:45 p.m., staff (S4 and S5) files are not readily available for review.
-at 4:00 p.m., resident's (R2) LIC9172 Functional Capability Assessment and LIC601 Identification and Emergency Contact Information were blank.
-at 4:05 p.m. to 4:30 p.m., all 4 residents' LIC625 Appraisal/Needs and Services Plan were over a year old.
-at 5:05 p.m. to 5:15 p.m., R2's 2 medications and R4's 1 medication have no doctor's order on file.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator.

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

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/18/2024 06:51 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/18/2024 at 05:49 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: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client 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 client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on records review, the licensee did not comply with the section cited above in 2 (R2 and R4) out of 4 residents have medications that do not have doctor's orders on file which pose an immediate health and/or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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Administrator stated he'll obtain doctor's orders. Copies to be submitted by 1/19/24.

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: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/18/2024 06:51 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/18/2024 at 05:49 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: 01/18/2024

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 for the side yard with door, pieces of wood, piece of gutter, chair frame, broken foos ball table. rusted chairs which poses a potential safety and/or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Administrator to have the yard cleaned and submit pictures by 2/01/24.
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for resident (R2) not having LIC9172 on file which poses potential health and/or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Admininistrator stated he'll complete the LIC9172. Copy to be submitted by 2/01/24.
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: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/18/2024 06:51 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/18/2024 at 05:49 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: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 4 out of 4 residents with outdated LIC625 which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Administrator to update the LIC625 and submit self-certification indicating the documents were completed.
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for resident (R2) not having LIC601 on file which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Administrator to complete the LIC601 and submit copy by 2/01/24.
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: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/18/2024 06:51 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/18/2024 at 06:12 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: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours…..

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, records review and interview, the licensee did not comply with the section cited above for staff's (S4 and S5) records not available for review and S2 not having LIC501 on file which pose a potential safety and/or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Administrator to ensure records will be available for review, Self-certification to be submitted by 2/01/24,
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
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