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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200305
Report Date: 12/23/2021
Date Signed: 12/23/2021 11:33:45 AM

Document Has Been Signed on 12/23/2021 11:33 AM - 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:AFU ONE VOICE CAREFACILITY NUMBER:
079200305
ADMINISTRATOR:AFU, ANAFACILITY TYPE:
735
ADDRESS:180 OAKPOINT COURTTELEPHONE:
(925) 457-7460
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
12/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Ana Afu, Licensee TIME COMPLETED:
11:45 AM
NARRATIVE
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On 12/23/2021 at 9:55am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Licensee Ana Afu and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility 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. Hand washing posters were observed. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks.

The following deficiency was observed during the visit:
10:15 am Backyard has trash
10:20am Expired cans of food found in pantry

Exit interview conducted. Appeal Rights and a copy of this report provided.


SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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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Document Has Been Signed on 12/23/2021 11:33 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 12/23/2021 at 11:14 AM
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: AFU ONE VOICE CARE
FACILITY NUMBER: 079200305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2021

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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Based on observation, the licensee did not comply with the section cited above by having trash in the backyeard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2021
Plan of Correction
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Clean up the backyard and send photo of correction by POC date
Type B
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

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 expired cans of food which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2021
Plan of Correction
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Check all of the food supply and throw away all expired foods. Send photo of cleaned out pantry 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2021


LIC809 (FAS) - (06/04)
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