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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601451
Report Date: 05/16/2022
Date Signed: 05/16/2022 04:32:57 PM


Document Has Been Signed on 05/16/2022 04:32 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:KARO MINA CARE HOMEFACILITY NUMBER:
075601451
ADMINISTRATOR:EWEDA, MONAFACILITY TYPE:
740
ADDRESS:2866 LARAMIE AVENUETELEPHONE:
(925) 551-8263
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 2DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mona Eweda, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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On 5/16/22 at 2:00 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPA was greeted by Care Staff, Berona Bronn. Administrator, Mona Eweda later arrived at 2:20 PM.

During the Infection Control Inspection, LPA toured facility with Administrator including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids.

During record review, LPA reviewed 3 staff records and 1 of 3 have health screening and TB test on file. Facility has a mitigation plan.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
  • At 2:52 PM, LPA observed staff are not fully vaccinated and does not have an exemption on file. In addition, weekly COVID-19 testing is not being conducted.
  • At 3:30 PM, LPA observed S1 is not fingerprint cleared.
  • At 3:32 PM, LPA observed S1 and S2 does not have health screening and TB test on file.


REPORT CONTINUES ON 809C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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: KARO MINA CARE HOME
FACILITY NUMBER: 075601451
VISIT DATE: 05/16/2022
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/20/2022
  • 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 (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

A Civil Penalty of $500 is being assessed.


Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/16/2022 04:32 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: KARO MINA CARE HOME
FACILITY NUMBER: 075601451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

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. LPA observed S1 is not fingerprint cleared which poses an immediate health and safety risk to person in care.
POC Due Date: 05/17/2022
Plan of Correction
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Effectively immediately, Administrator will discontinue S1 from providing care to residents and remove S1 from facility until fingerprint cleared. Administrator will review regulation and submit a self-certification letter and a copy of live scan for S1 by POC date.

$500 CIVIL PENALTY IS ASSESSED
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 05/16/2022 04:32 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: KARO MINA CARE HOME
FACILITY NUMBER: 075601451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)(2)
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based record review and interview,, the licensee did not comply with the section cited above. LPAs observed 3 staff are not fully vaccinated and does not have an exemption on file nor is conducting weekly COVID-19 testing which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2022
Plan of Correction
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By POC date, Administrator agrees to obtain an exemption and conduct weekly COVID-19 for all staff who are not classified as "fully vaccinated" in accordances to Local County Health Order and PIN 22-05.1-ASC or be fully vaccinated and submit proof to CCL.
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.......

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. LPA observed S1 and S2 does not have a health screening and TB test on file which poses a potential health and safety risk to residents in care.
POC Due Date: 05/30/2022
Plan of Correction
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By POC date, Administrator agrees to obtain a health screening and TB test for both S1 and S2 and submit a copy to CCL.

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7