019201338-3-6-2024-15-AS-ADEO-D34T5Y-20240306132621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019201338
Report Date: 03/06/2024
Date Signed: 03/06/2024 01:27:02 PM

Document Has Been Signed on 03/06/2024 01:27 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:	MOONRAKER VILLA SENIOR CARE 2		FACILITY NUMBER:	019201338
ADMINISTRATOR:	AKAOSUGI, YONG		FACILITY TYPE:	740
ADDRESS:	22052 MAIN STREET		TELEPHONE:	(510) 776-6084
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	6	CENSUS: 0	DATE:	03/06/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Yong Akaosugi/Applicant-administrator.		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 10:35 a.m. on this day, March 6, 2024, Licensing Program Analysts (LPAs) Alicia Delmundo and Tonica Syess-Gibson conducted an announced pre-licensing inspection, and met with Yong Akaosugi, applicant-administrator. License application is for six (6) total capacity, of which 2 may be non-ambulatory. Fire clearance was granted on January 16, 2024. Applicant submitted the LIC9282 Infection Control Plan and updated LIC610E Emergency Disaster Plan to Central Application Bureau (CAB) analyst. LPAs toured the facility inside out with applicant. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. Facility is a two level home on which residents will be housed on the first floor. LPAs inspected the living and family rooms, kitchen, bedrooms, bathrooms, front, side and backyard and garage. Bedrooms were observed appropriately furnished with adequate lighting and drawers. The facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed adequate for residents' use. There’s 7 days supplies of non-perishables and 2 days of perishables. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. Storages where knives and medications will be centrally stored were observed with locks. Facility has auditory signals on all exit doors, and call buttons are readily available for residents' use. Bathrooms were observed with grab bars and non-skid mats. Fire extinguishers were observed fully charge and tags showed serviced August 2, 2023. Facility has carbon monoxide and smoke detectors that were tested, and observed operational. First aid kit inspected. Facility has flash lights for emergency lighting. Hot water temperature in the bathroom was tested and measured at 108.1 degress Fahrenheit. ....continued on 809C (page 2)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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 7

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: MOONRAKER VILLA SENIOR CARE 2	FACILITY NUMBER: 019201338
	VISIT DATE: 03/06/2024

NARRATIVE

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Page 2

One of the residents' rooms was observed with security window bar and with safety release device that was approved by the fire department. One of the other room has fireplace which was observed with lock. Facility has fish pond in the backyard which was observed door was secured with lock.

Ombudsman and complaint posters, Right to Resident Council, Right to Family Council, Theft and Loss Program/Policy and Residents Personal Rights were observed posted in the prominent place.

LPAs observed the following:
-at 10:38 a.m., front door with sliding metal latch where one can put lock.
-at 11:19 a.m., uneven ground/surface in the side yard.
-at 11:40 a.m., cameras inside the common areas and outside the facility which have audio feature.
-at 11:50 a.m., first aid kit with no tweezer and manual.
-facility sketch does not indicate the dining area.
-Complaint poster not of the required size.

Applicant to do the following and submit proof of corrections by March 20, 2024:
1. Remove the metal latch on the front door, and submit picture.
2. Fill the uneven surface gravel and sand, and submit picture --see LIC9102 Technical Assistance
3. Remove the cameras, and submit pictures.
4. Purchase tweezer and manual, and submit proof of purchase and/or picture --see LIC9102.
5. Applicant re-arranged the furniture; however, updated sketch showing dining area to be submitted.
6. Post Complaint Poster with required size - see LIC9102.

.....continued on 809C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

Page: 2 of 7

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: MOONRAKER VILLA SENIOR CARE 2	FACILITY NUMBER: 019201338
	VISIT DATE: 03/06/2024

NARRATIVE

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LPAs reminded the applicant of the following before or upon admission of first resident:
· Obtain $3M Liability Insurance coverage, and submit copy to LPA Delmundo.
· Updated copy of LIC500 Personnel Report.
· Updated copy of LIC308 Designation of Facility Responsibility

LPA Delmundo will inform CAB analyst upon receipt of proof of corrections. Final review of application, and license to be granted by CAB analyst.

Exit interview conducted, and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

Page: 3 of 7