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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600211
Report Date: 12/12/2023
Date Signed: 12/12/2023 05:35:22 PM

Document Has Been Signed on 12/12/2023 05:35 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:FELY-MAR ELDERLY CARE HOMEFACILITY NUMBER:
075600211
ADMINISTRATOR:MARIANO, FELINORFACILITY TYPE:
740
ADDRESS:2268 HIGHLANDS ROADTELEPHONE:
(510) 724-3248
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 5CENSUS: 4DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:MAE MORALES, CAREGIVERTIME COMPLETED:
06:00 PM
NARRATIVE
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On 12/12/2023 at 9:15am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Mae Morales, Caregiver, and explained the purpose of the visit. Emcy Levin, Administrator arrived at 10:45am. The Administrator currently holds a certificate (#6013527740) that expires on 03/15/2024. The facility’s fire clearance was approved for five (5) non-ambulatory residents.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms which two (2) bedrooms are occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 115.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/25/2023. First aid kit was observed to be complete.

Facility did not have staff files available for file review.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 12/12/2023
NARRATIVE
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Continued from LIC809.

LPA observed the following deficiencies:

· At 9:55am, LPA observed cold and flu medication in the refrigerator.
· At 9:57am, LPA observed sharps in an unlocked cabinet in the kitchen.
·At 9:59am, LPA observed facility did not have 7-day of non-perishable and 2-day of perishable foods available for residents.
· At 10:03am, LPA observed cleaner, such as Clorox disinfectant, comet, and other chemicals in unlocked cabinet underneath kitchen sink.
·At 10:07am LPA observed a knife, oxy clean, clorox, toilet bowl cleaner, bleach in an unlocked garage.
· At 10:10am, LPA observed clorox spray, comet, and lysol in shared bathroom.
  • At 10:12am, LPA observed shower is inoperable.
· At 10:14am, LPA observed 3 storage spaces unlocked with chemicals, knife, weed eater, paint, and glass cleaner.
· At 10:18am, LPA observed an uncovered hole in the backyard approximately 15 inches deep.
  • At 10:25am, LPA observed stacked boxes and roundup weed killer in front yard.
  • At 11:00am, LPA during file review observed that the facility did not have staff files located at the facility.



Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
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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: 12/12/2023
NARRATIVE
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CONTINUED FROM LIC 809

LPA requested the following documents to be submitted to CCLD by 12/29/2023.

· Resident Roster
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
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Document Has Been Signed on 12/12/2023 05:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 12/12/2023 at 02:53 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: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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.

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 by having chemicals such as clorox, comet, toilet bowl cleaner, bleach and fabuloso in unlocked cabinets in kitchen and bathrooms which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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Administrator locked locks in kitchen, garage and both bathrooms with the chemicals. Deficiency cleared during visit.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, the licensee did not comply with the section cited above by having 3 unlocked storage units with clorox, windex, ladders, lawn mower, weed eater, shovels, propane tanks accessible to residents in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
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3
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Administrator agreed to purchase locks and lock the 3 storage units no later than the POC date and email a photo copy of the storage units locked.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


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Document Has Been Signed on 12/12/2023 05:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 12/12/2023 at 02:53 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: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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 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 by having a hole approximately 15 inches deep located in the back yard which poses a potential health and safety risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator agreed to have the hole in the back yard filled and provide photo copies to CCLD via email no later than the POC date.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having the shower in bathroom #1 in operating condition which poses a potential health and safety risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator agreed to get a professional plumbing company to repair the shower and provide CCLD a copy of the invoice no later than the POC date.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


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Document Has Been Signed on 12/12/2023 05:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 12/12/2023 at 02:53 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: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not having staff records maintained at the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator will provide CCLD a copy of all staff files via email no later than the POC date.
Type B
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above by staff training requirements not met which poses a potential health and safety risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator agreed to forward copies of all updated education and medication training's for all staff.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2023 05:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 12/12/2023 at 02:53 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: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(2)
Incidental Medical and Dental Care Services
(d) If the resident 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 resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having documentation of prescribed medications for residents which poses a potential health and safety risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator agreed to maintain documentation from residents Physicians and create a MAR to keep track of daily dispensing of medication.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident 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 resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not maintaining documentation of residents prescribed PRN medication which poses a potential health and safety risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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2
3
4
Administrator agreed to maintain documentation from residents Physicians and create a MAR to keep track of daily dispensing of PRN medication.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2023 05:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 12/12/2023 at 02:53 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: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above by not having documentation of disaster drills being conducted which poses a potential health and safety risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
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2
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Administrator agreed to conduct in-service training on staff responsibilities during a disaster drill. document and email CCLD a copy of the sign in sheet with topic of training date, time and name of trainer no later than the POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above by not conducting emergency disaster drills quarterly which poses a potential health and safety risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
1
2
3
4
Administrator agreed to conduct a disaster drill, document and email a copy of document to CCLD no later than the POC date.
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:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 12/12/2023 05:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 12/12/2023 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: FELY-MAR ELDERLY CARE HOME
FACILITY NUMBER: 075600211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication.

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 by having centrally stored medication located in an unlocked refrigerator accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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2
3
4
Administrator is to train staff on the importance of ensuring that centrally stored medication is to be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication. Training topics and signature of attendees to be submitted to CCL 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
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


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