075601541-5-5-2023-15-AS-LHOS-CRK3NZ-20230505182446

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601541
Report Date: 05/05/2023
Date Signed: 05/05/2023 06:25:48 PM

Document Has Been Signed on 05/05/2023 06:25 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:	WAGAYA ASSISTED LIVING		FACILITY NUMBER:	075601541
ADMINISTRATOR:	KATSUMOTO, MINORU		FACILITY TYPE:	740
ADDRESS:	905 ELM STREET		TELEPHONE:	(510) 965-7678
CITY:	EL CERRITO	STATE: CA	ZIP CODE:	94530
CAPACITY:	6	CENSUS: 6	DATE:	05/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Minoru Katsumoto, Administrator		TIME COMPLETED:	06:45 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 05/05/23 at 01:15 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual inspection. LPA met with Minoru Katsumoto, Administrator, and explained the purpose of the visit. ADM currently holds a standard certificate (6019180740) that expires 08/09/24. The facility’s fire clearance was approved for six (6) non-ambulatory residents; two (2) may have hospice waivers. Upon arrival LPA observed three (3) staff monitoring the facility and attending to residents that were watching television in the common area. LPA and ADM toured the facility including, but not limited to bathrooms, kitchen, common areas, laundry area, dining area, front yard and backyard. The facility consists of 5 (five) bedrooms. All outdoor and indoor passageways are free of obstruction. There were no bodies of water. A comfortable temperature was maintained at 71 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared residents' bathroom was measured at 110.5 degrees (F). All toilets, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing signs, paper towels, and soap observed at all hand washing stations. Linen and hygiene products available for all residents. PPE, sanitizer, and paper goods remain sufficient. ...continued on LIC9099C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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 29

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: WAGAYA ASSISTED LIVING	FACILITY NUMBER: 075601541
	VISIT DATE: 05/05/2023

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
26
27
28
29
30
31
32

...continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and new tag to be replaced on 12/13/22. Emergency Disaster Plan is updated.

Three (3) staff records were reviewed, and all staff have criminal record clearances. Five (5) residents records were reviewed and are incomplete.

The following forms are to be updated and submitted to CCLD by 05/12/23:
-Resident Roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan
-Create emergency binder, organize staff and resident files with dividers and tabs and provide photos to CCLD by 06/05/23.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Repeat violation(s) within a 12-month period and/or failure to correct deficiencies may result in civil penalties.

Exit interview conducted, appeal rights and a copy of this report provided to ADM.

Exit interview conducted and a copy of this report provided to ADM.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 29

Document Has Been Signed on 05/05/2023 06:25 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: WAGAYA ASSISTED LIVING	FACILITY NUMBER: 075601541
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 staff not having first aid and/or CPR which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2023
	Plan of Correction
1 2 3 4	Administrator and staff to schedule first aid and CPR training, and provide proof to CCL by the POC date.

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 6 out of 6 residents centrally stored medication records not being current and recorded which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2023
	Plan of Correction
1 2 3 4	Administrator and staff to review the regulation 87465, update all residents' centrally stored medication records, and all staff self certify by signing and dating correction. This is to be submitted to CCL by 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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

Page: 3 of 29

Document Has Been Signed on 05/05/2023 06:25 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: WAGAYA ASSISTED LIVING	FACILITY NUMBER: 075601541
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 in 6 out of 6 residents' medication that was prepared in advance and not updated on the medication administration records (MAR) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2023
	Plan of Correction
1 2 3 4	Administrator and staff to review the regulation 87465, update all residents' MAR's and all staff self certify by signing and dating correction. This is to be submitted to CCL by 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 observation, interview and record review, the licensee did not comply with the section cited above by not any performing any emergency disaster drills for the year of 2023 with staff and residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Administrator shall conduct the first drill by POC date and continue disaster drills at least quarterly for each shift. Administrator and staff to review HSC 1569.695, update disaster log, and have all staff self certify by signing and dating correction. This is to be submitted to CCL by 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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

Page: 4 of 29