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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601127
Report Date: 04/25/2024
Date Signed: 04/25/2024 07:35:18 PM


Document Has Been Signed on 04/25/2024 07:35 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:MAYON BOARD AND CARE, INC.FACILITY NUMBER:
075601127
ADMINISTRATOR:PANELO, ARTHUR H.FACILITY TYPE:
740
ADDRESS:1804 CONCORD COURTTELEPHONE:
(925) 825-5593
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 6DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jovito Panelo Jr., CareGiver
Arthur Panelo, Administrator		TIME COMPLETED:
08:00 PM
NARRATIVE
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On 4/25/2024 at 3:00 PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with staff Jovito Panelo. LPA spoke with Administrator, Arthur Panelo and explained the purpose of the visit. LPA have verbal permission for staff Leven to sign the report. The facility’s fire clearance was approved for 6 Non ambulatory.

LPA toured facility with Jovito including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are 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. Residents’ bathroom is equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication is inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. LPA observed a purchased extinguisher with receipt attached dated 5/3/2023. First aid kit was observed to be complete.

LPA reviewed 5 residents records. LPA reviewed 3 staff records and 2 of 3 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications.

Report continues on 809 C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 by hot water measure at 127.9 F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator will correct the hot water tempurate and submit picture to CCLD by POC date.
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 cleaning and detergent are left unlock in the garage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator will lock up all cleaning chemical and submit proof to CCLD by 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
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
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Based on observation the licensee did not comply with the section cited above knives was left unlock under the sink cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Staff lock knives during inspection. Deficency clear
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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 07:35 PM - It Cannot Be Edited

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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.33(h)
Regulations
(h) As a part of the department’s evaluation process, the department shall review the plan of operation, training logs, and marketing materials of any residential care facility for the elderly that advertises or promotes special care, special programming, or a special environment for persons with dementia to monitor compliance with Sections 1569.626 and 1569.627.

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 in facility do not have staff training records on files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator will submit staff training records to CCLD by POC date.
Type B
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above by not having fire clearance for bedridden resdient, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Administrator will submit fire clearance approve for bedridden to CCLD by 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 07:35 PM - It Cannot Be Edited

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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

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 there are no proof of current liability insurance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator will submit a current liability insurance to CCLD by POC date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 facility window screen is in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator will photo of fix window screen to CCLD by 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 07:35 PM - It Cannot Be Edited

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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(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
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Based on observation, the licensee did not comply with the section cited above observed to have boxes blocking the emergency gate on the side of the building. Bed frame, mattress, and a tall table are blocking passageway, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator will remove boxes blocking the emergency gate on the side of the building. Bed frame, mattress, and a tall table are blocking passageway, and send picture to CCLD by POC date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 do not have CRP and first Aid certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator will submit staff CPR and First Aid to CCLD by 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 07:35 PM - It Cannot Be Edited

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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

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 did no see designated notice on files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator will send CCLD proof of designated form to CCLD by POC date.
Type B
Section Cited
CCR
87412(e)
Personnel Records
(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above facility do not have an LIC 500, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator will send CCLD proof of LIC 500 form to CCLD by 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 07:35 PM - It Cannot Be Edited

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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

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 food that are not stored properly that are not eatable, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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Administrator will send picutre of proper storage to CCLD by POC.
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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4
Based on record review the licensee did not comply with the section cited above by not keeping reocord of resident medication, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administator will submit residents record of medication to CCLD by 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 8 of 12


Document Has Been Signed on 04/25/2024 07:35 PM - It Cannot Be Edited

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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above by not having resident recent medical assessment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator will update medical assessment for resident and submit to CCLD by POC date.
Type B
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having a proper fire clearance for bedridden resident, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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2
3
4
Administrator will submit proof of a proper fire clearance for bedridden to CCLD by 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2024 07:35 PM - It Cannot Be Edited

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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(f)(3)
Care of Bedridden Residents
(f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having staff training of bedridden to care for resident that are on bedridden, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
1
2
3
4
Administrator will sumbit staff bedridden training to CCLD by POC date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by nit having a current physician report for residents with dementia, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
1
2
3
4
Administrator will update all resident physician report to CCLD by 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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 10 of 12


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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127
VISIT DATE: 04/25/2024
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/17/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiencies were observed:

3:10pm knives observed under sink left unlock.

3:15pm chemical in garage are left unlock.

3:20pm observed expired can goods in the garage, and green are not good eating condition.

3:30pm observed to have boxes blocking the emergency gate on the side of the building. Bed frame, mattress, and a tall table are blocking the emergency exit.

3:35pm observed window screens out the side door is disrepair.

3:40pm observed and tested resident hot water to be 127.9.

3:50pm Resident Medication log (MAR) are not being kept constantly.

4:30pm Resident record review physician report are not up to date with dementia resident.

4:50pm Staff record review missing files all files except for fingerprint/ background clearance.

Report continue on LIC 809c

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 11 of 12
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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127
VISIT DATE: 04/25/2024
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5:15pm Resident with dementia do not have current MA on files.

5:30pm Resident do not have an update needs and service plan.

6:00pm facility do not have an appropriate fire clearance for bedridden.

The following deficiencies were observed (see LIC 809 D) and cited from the California Code of Regulations, Title 22 and Failure to correct deficiencies by POC date may result in additional Civil Penalties.



Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 12 of 12