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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601451
Report Date: 01/12/2026
Date Signed: 01/12/2026 04:28:25 PM

Document Has Been Signed on 01/12/2026 04:28 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:KARO MINA CARE HOMEFACILITY NUMBER:
075601451
ADMINISTRATOR/
DIRECTOR:		EWEDA, MONAFACILITY TYPE:
740
ADDRESS:2866 LARAMIE AVENUETELEPHONE:
(925) 551-8263
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6CENSUS: 2DATE:
01/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator, Mona EwedaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 1/12/2026 at 1:00 PM, Licensing Program Analysts (LPAs) A. Gomez and Y Brown arrived unannounced to continue the Required 1 Year Annual inspection. Upon arrival, LPA was greeted by Caregiver, Ulanda Mitchell and explained the purpose of the visit. Administrator arrived at 2:00PM. The facility’s fire clearance was approved for 6 Non-Ambulatory.

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPAs 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 113.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were not locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 01/28/2025. Emergency Disaster Plan was last posted on 01/01/2026. First aid kit was observed to be complete. Emergency disaster drill was last conducted on December 2025.

At 1:40pm, LPA reviewed 2 residents records. At 2:30 pm, LPA reviewed 2 staff records.

REPORT CONTINUES ON LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: KARO MINA CARE HOME
FACILITY NUMBER: 075601451
VISIT DATE: 01/12/2026
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • LPAs observed a pair of scissors with a blue handle located in the kitchen on top of the microwave (Repeat Violation)
  • LPAs observed Vicks formula 44DM cough syrup on R1's bedside table
  • Facility not properly documenting the use of R1's PRN cough syrup
  • R2's appraisal of needs and services is incomplete
  • S2's File incomplete
  • LPAs observed the administrator in poor health (leg injury that they state requires surgery) that could impair their ability to provide care
  • Facility did not have planned activities.
  • LPAs observed PUB475 is the incorrect size


Based on observations LPAs are requesting that R2 get an updated physicians report after visiting the doctor.

***Civil Penalties assessed in the amount of $250 for repeat violations***


Updated copies of the following documents were requested for facility file and are to be mailed to CCL by 1/21/2026:

LIC 500 Personnel Report
Liability Insurance
Current Administrator’s Certificate
Emergency Distaster Plan LIC610E


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code 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.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 01/12/2026 04:28 PM - It Cannot Be Edited


Created By: Alona Gomez On 01/12/2026 at 03:13 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: KARO MINA CARE HOME
FACILITY NUMBER: 075601451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 in having a pair of scissors with a blue handle acessible to residents located in the kitchen on top of the microwave which poses an immediate safety risk to persons in care.
POC Due Date: 01/13/2026
Plan of Correction
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Administrator removed and locked the scissors in a cabinet. DEFICIENCY CLEARED DURING VISIT.
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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/12/2026 04:28 PM - It Cannot Be Edited


Created By: Alona Gomez On 01/12/2026 at 03:13 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: KARO MINA CARE HOME
FACILITY NUMBER: 075601451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
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. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 in that the administrator stated that they have a leg injury that requires surgery which poses a potential health and safety risk to persons in care.
POC Due Date: 01/19/2026
Plan of Correction
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By POC date, the Administrator agrees to appoint an additional staff member to assist the facility during their shifts and notify CCLD.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 01/12/2026 04:28 PM - It Cannot Be Edited


Created By: Alona Gomez On 01/12/2026 at 03:13 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: KARO MINA CARE HOME
FACILITY NUMBER: 075601451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(4)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (4) Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license.

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 that S2's personnel file is missing their identifying document and LIC501 which poses a potential personal rights risk to persons in care.
POC Due Date: 01/19/2026
Plan of Correction
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By POC date, Administrator agrees to complete S2's personnel file including their identifying documents and LIC501 and notify CCLD.
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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 01/12/2026 04:28 PM - It Cannot Be Edited


Created By: Alona Gomez On 01/12/2026 at 03:13 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: KARO MINA CARE HOME
FACILITY NUMBER: 075601451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

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 in that the PUB475 is the incorrect size which poses a potential personal rights risk to persons in care.
POC Due Date: 01/19/2026
Plan of Correction
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By POC date, the administrator agrees to obtain the correct 20 X 26 PUB475 poster and notify CCLD.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 01/12/2026 04:28 PM - It Cannot Be Edited


Created By: Alona Gomez On 01/12/2026 at 03:13 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: KARO MINA CARE HOME
FACILITY NUMBER: 075601451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

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 in the facility not having any planned activities or an activity calendar which poses a potential personal rights risk to persons in care.
POC Due Date: 01/19/2026
Plan of Correction
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By POC date, the Administrator agrees to create an activity calendar that details planned activities for residents and notify CCLD.
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

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 in that there was Vicks formula 44DM cough syrup on R1's bedside table accessible which poses a potential safety risk to persons in care.
POC Due Date: 01/19/2026
Plan of Correction
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Administrator removed the Vicks formula 44DM cough syrup and locked it in the medication cabinet. DEFICIENCY CLEARED DURING VISIT.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 01/12/2026 04:28 PM - It Cannot Be Edited


Created By: Alona Gomez On 01/12/2026 at 03:13 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: KARO MINA CARE HOME
FACILITY NUMBER: 075601451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
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:

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 in that the facility did not have proper documentation of the PRN, notification to the physicians or a log of the dosages being taken which poses a potential safety risk to persons in care.
POC Due Date: 01/19/2026
Plan of Correction
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2
3
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By POC date, the Administrator agrees to review the procedure, update files accordingly and notify CCLD.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 in that R1's Appraisal needs and Services Plan was incomplete which poses a potential personal rights risk to persons in care.
POC Due Date: 01/19/2026
Plan of Correction
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2
3
4
By POC date, the Administrator agrees to complete R1's Appraisal needs and services plan and notify CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


LIC809 (FAS) - (06/04)
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