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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200285
Report Date: 09/26/2023
Date Signed: 09/26/2023 01:10:05 PM

Document Has Been Signed on 09/26/2023 01:10 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:VIA CENTERFACILITY NUMBER:
079200285
ADMINISTRATOR:MCGEE, ANGELAFACILITY TYPE:
735
ADDRESS:133 HEATHER DRIVETELEPHONE:
(415) 613-9372
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 5DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Debelo Fufa, CaregiverTIME COMPLETED:
01:20 PM
NARRATIVE
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On 9/26/2023 at 09:40am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Debelo Fufa, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Angela McGee via telephone. House Manager, Deberitu Mekonnen, arrived at 12:00pm. Administrator certificate #6006628735 expires 11/24/2023. Facility's fire clearance is for six (6) ambulatory and one (1) non-ambulatory client.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, and back yard. The facility consists of four (4) total bedrooms and three (3) bathrooms. One (1) bedroom is occupied by staff. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 114.8 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Emergency disaster plan updated 5/10/2020. Fire extinguisher was last services on 11/25/2022. Last fire drill conducted 7/7/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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: VIA CENTER
FACILITY NUMBER: 079200285
VISIT DATE: 09/26/2023
NARRATIVE
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Continued from LIC809.

LPA reviewed all five (5) client records and none contained an appraisal needs and services plan. LPA reviewed three (3) staff files and all were complete and first aid certified. One (1) staff file was not present for review.

LPA observed the following deficiencies:
  • At 09:45am, LPA observed S2 was fingerprint cleared.
  • At 10:40am, LPA observed during record review clients; P & I cash safeguard sheet was not accurate.
  • At 10:50am, LPA observed insect traps with expired insects sitting on kitchen counter top and on staff bedroom floor.


LPA requested the following documents to be submitted to CCLD by 10/3/2023.
  • Client roster
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610D Emergency Disaster Plan (9 pages)
  • Surety Bond
  • Liability insurance


*An immediate civil penalty of $500.00 will be assessed for fingerprint.

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 LIC421BG, appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2023 01:10 PM - It Cannot Be Edited


Created By: Laura Hall On 09/26/2023 at 12:35 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: VIA CENTER
FACILITY NUMBER: 079200285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(d)
80019 Criminal Record Clearance

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

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 in having S2 fingerprinted and associated which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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Administrator agreed to get S2 fingerprinted and submit invoice to CCLD by POC date.
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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2023 01:10 PM - It Cannot Be Edited


Created By: Laura Hall On 09/26/2023 at 12:40 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: VIA CENTER
FACILITY NUMBER: 079200285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having cash safeguard document accurate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2023
Plan of Correction
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Administrator agreed to submit a copy of an accurate cash safeguard document to CCLD by POC date.
Type B
Section Cited
CCR
80076(15)
80076 Food Services

(15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are 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 having sticky traps off kitchen counter top which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2023
Plan of Correction
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Caregiver immediately removed sticky traps and House Manager showed invoice to LPA where exterminator came out on 8/30/2023. 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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