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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200285
Report Date: 08/26/2025
Date Signed: 08/26/2025 01:38:13 PM

Document Has Been Signed on 08/26/2025 01:38 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/
DIRECTOR:		MCGEE, ANGELAFACILITY TYPE:
735
ADDRESS:133 HEATHER DRIVETELEPHONE:
(415) 613-9372
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 5DATE:
08/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:DEBELO FUFA, CARE GIVERTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
NARRATIVE
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On 08/26/2025 at 09:50 AM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge conducted an unannounced annual 1-year required inspection. LPAs met with Debelo Fufa, Caregiver and explained the purpose of the visit. House Manager Deberitu Mekonnen arrived at 10:30am, Administrator certificate #7034452735 expires 11/24/2025. Facility's fire clearance is for six (6) ambulatory and one (1) non-ambulatory client.

LPAs 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 72 degrees Fahrenheit. LPAs 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 105 degrees Fahrenheit. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2025
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 6
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: VIA CENTER
FACILITY NUMBER: 079200285
VISIT DATE: 08/26/2025
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CONTINUE ON FROM LIC 809

Smoke detectors/carbon monoxide were in operating condition during visit. Emergency disaster plan updated 08/26/2025. Fire extinguisher was last services on 1/09/2024. Last fire drill conducted 06/09/2025. First aid kit was observed to be complete.

LPAs reviewed three (3) client records; all complete. LPAs reviewed three (3) staff files;two (2) were missing health screening reports.

LPAs observed the following deficiencies:
  • At 10:15 AM, LPAs observed kitchen sink needs repair and is stained. Refrigerator drawer was broken, dresser draw in room 4 off track, two ladder, rug shampooer and bookshelf in backyard.
  • At 10:25 AM, LPA observed two bedrooms, 3&4, and living room windown were missing screens.
  • At 10:55 LPAs observed health screening missing for two (2) staff; Administrator and caregiver.


LPAs requested the following documents to be submitted to CCLD by 09/02/2025.
  • 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

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 this report and appeals rights provided
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/26/2025 01:38 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/26/2025 at 12:16 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: 08/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 by having fabuloso in an unlocked bathroom vanity, which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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House Manager locked up fabuloso during visit. DEFFICIANCY CLEARED DURING VISIT.
Type A
Section Cited
CCR
80020(a)
80020(a) Fire Clearance
a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based upon LPAs observation Administrator did not comply with having up-to-date fire extinguishers, which poses a potential health and safety risk to clients.
POC Due Date: 08/27/2025
Plan of Correction
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Administrator agreed to have fire extinguishesr serviced or purchase new fire extinguisher and sumbit 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2025 01:38 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/26/2025 at 12:17 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: 08/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, the licensee did not comply with the section cited above
by kitchen sink needing repair and is stained. Refrigerator drawer was broken, dresser draw in room 4 off track, two ladder, rug shampooer and bookshelf in backyard. which poses a potential health and safety risk to persons in care.
POC Due Date: 09/09/2025
Plan of Correction
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Administrator agrees to replace and remove Based on observation, the licensee did not comply with the section cited above by kitchen sink needing repair and is stained. Refrigerator drawer was broken, dresser draw in room 4 off track, two ladder, rug shampooer and bookshelf in backyard and submitt photos to the department by the POC date.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 two bedrooms, rooms 3&4, and living room windown missing screens. which poses a potential health and safety risk to persons in care.
POC Due Date: 09/09/2025
Plan of Correction
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Administrator agrees to replace two bedrooms, rooms 3&4, and living room windown screens and submitt photos to the department 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2025 01:38 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/26/2025 at 01:03 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: 08/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
(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:

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 two (2) staff, S! and S1, missing health screen report, which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 09/09/2025
Plan of Correction
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Administrator agrees to obtain a health screen report for S1 and S2 and submit a copy of 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2025


LIC809 (FAS) - (06/04)
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