075600211-10-13-2021-15-AS-CFOR-C7RTD5-20211013143746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600211
Report Date: 10/13/2021
Date Signed: 10/13/2021 02:37:55 PM

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:	FELY-MAR ELDERLY CARE HOME		FACILITY NUMBER:	075600211
ADMINISTRATOR:	MARIANO, FELINOR		FACILITY TYPE:	740
ADDRESS:	2268 HIGHLANDS ROAD		TELEPHONE:	(510) 724-3248
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	5	CENSUS: 3	DATE:	10/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	FELINOR M. MARIANO, Administrator		TIME COMPLETED:	02:50 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	On 10/13/2021 at 11:05 am, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Felinor Mariano and explained the purpose of the visit. Upon entry, LPA's temperature was not checked. LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters. During record review, LPAs did not observed visitors log and temperature logs for residents or staff. LPAs observed facility has a copy of Mitigation Plan on file. The following deficiencies were observed during the visit: -At 11:10Am, LPAs observed S2 was not associated to facility. -At 11:20am, LPAs observed a knife in drainer sitting on kitchen counter top and knives in unlocked kitchen cabinet. -At 11:22am, LPAs observed Ajax and raid in unlocked cabinet underneath the kitchen sink. -At 11:23am, LPAs observed a power saw, WD-40,detergent, and disinfectant accessible in the unlocked garage. -At 11:35am, LPAs observed a shovel, hammer, a panel of glass, and 4 ladders in the backyard. Continued on LIC809.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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: FELY-MAR ELDERLY CARE HOME	FACILITY NUMBER: 075600211
	VISIT DATE: 10/13/2021

NARRATIVE

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Continued on LIC809C.

-At 11:40am LPAs observed iron gate parts, BBQ grill, and a door obstructing the emergency exit from the backyard.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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: FELY-MAR ELDERLY CARE HOME	FACILITY NUMBER: 075600211
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 knives, toxins, and tools accessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2021
	Plan of Correction
1 2 3 4	Administrator agreed to make tools, knives, and toxins inaccessible and submit photo to CCLD by POC date. During visit Administrator placed knives and toxins in garage, and reversed lock on garage door. Administrator will remove or make tools and ladders unaccessible in backyard and submit a 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC809 (FAS) - (06/04)

Page: 4 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: FELY-MAR ELDERLY CARE HOME	FACILITY NUMBER: 075600211
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

87307 Personal accomendation 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in emergency exit from backyard obstructed by iron gates, BBQ grill and a door posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2021
	Plan of Correction
1 2 3 4	Administrator agreed to have obstructions removed from blocking emergency exit and submit a 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC809 (FAS) - (06/04)

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