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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200305
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:48:45 PM

Document Has Been Signed on 12/08/2022 03:48 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: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:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Ana Afu, AdministratorTIME COMPLETED:
03:55 PM
NARRATIVE
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On 12/8/2022 at 1:50PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Ana Afu, Administrator and explained the purpose of the visit.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted above screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, and kitchen. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 137.8 degrees Fahrenheit. Fire extinguisher last serviced on 12/14/2021.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the mitigation plan on file.


LPA request the following documents to be submitted to CCLD by 12/15/2022.
  • LIC610D Emergency Disaster Plan
  • LIC500 Personnel Report
  • LIC9282 Infection Control Plan.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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 7
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: AFU ONE VOICE CARE
FACILITY NUMBER: 079200305
VISIT DATE: 12/08/2022
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Continued from LIC809.

The following deficiencies was observed:
  • LPA observed facility did not have a minimum of 7-day non-perishables and 2-day perishable food for clients.

  • LPA observed rug, plastic runners, refrigerator, and freezer unsanitary. Blinds, ceiling light fixture, wall light fixture, and both sinks in clients bathroom located upstairs in disrepair.

The following deficiencies was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7
Document Has Been Signed on 12/08/2022 03:48 PM - It Cannot Be Edited


Created By: Laura Hall On 12/08/2022 at 03:16 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: AFU ONE VOICE CARE
FACILITY NUMBER: 079200305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings 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 in having facility sanitary and in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2022
Plan of Correction
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Administrator agreed to replace broken fixtures, sinks, and blind in clients bathroom, clean rugs plastic runners, refrigerator, and freezer, and submit photos to CCLD by POC date.
Type B
Section Cited
CCR
85076(d)(1)
85076 Food Service

(d) The licensee shall meet the following food supply and storage requirements:

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two day

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 minimum of 7-day non-perishables and 2-days perishables food for clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2022
Plan of Correction
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Administrator agreed to purchase food and send photo and receipt 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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