<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079200305
Report Date:
12/15/2023
Date Signed:
12/15/2023 05:12:03 PM
Document Has Been Signed on
12/15/2023 05:12 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 CARE
FACILITY NUMBER:
079200305
ADMINISTRATOR:
AFU, ANA
FACILITY TYPE:
735
ADDRESS:
180 OAKPOINT COURT
TELEPHONE:
(925) 457-7460
CITY:
BAY POINT
STATE:
CA
ZIP CODE:
94565
CAPACITY:
6
CENSUS:
5
DATE:
12/15/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:25 PM
MET WITH:
Ana Afu, Administrator
TIME COMPLETED:
05:20 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 12/15/2023 at 1:25pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson conducted an unannounced annual 1-year required inspection. LPA met with Ana Afu, Administrator
and explained the purpose of the visit. The administrator currently holds a certificate (#6017513735) that expires on 09/12/2024. The facility’s fire clearance was approved for six (6) ambulatory clients.
LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) total bedrooms and three (3 ) bathrooms. Two (2) bedrooms being used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 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 137.1 degrees Fahrenheit. All toilets were 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.
Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 12/20/2022. First aid kit was observed to be complete.
Continued on LIC809C.
SUPERVISORS NAME
:
Harpreet Humpal
LICENSING EVALUATOR NAME
:
Laura Hall
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/15/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/15/2023
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
8
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:
12/15/2023
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 LIC809.
LPAs reviewed all five (5) client files and all are incomplete. LPAs reviewed one (1) staff file and it was incomplete. Administrator did not have files for any other staff.
The following forms to be updated and submitted to CCLD
by 12/22/2023
:
LIC610D Emergency disaster plan (all 9 pages)
Liability insurance.
LIC500 (Personnel Record)
Client Roster
LIC308 (Designation of facility Responsibility)
LPA observed the following deficiencies:
At 2:10pm, LPAs observed during record all five (5) clients files were incomplete.
At 2:15pm, LPAs observed facility only had one (1) staff file available but incomplete.
At 2:20pm, LPAs observed Licensee have not paid licensee fees and is far behind.
At 2:30pm, LPAs observed facility did not have a minimum supply of 7-day non-perishable and two day perishable foods for clients.
At 2:35pm, LPAs observed 2 bedrooms did not have night stands, 1 bedroom did not have a chest of drawers. One bedroom needs blinds replaced. One bedroom needs a lamp.
Continued on LIC809C.
SUPERVISORS NAME
:
Harpreet Humpal
LICENSING EVALUATOR NAME
:
Laura Hall
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/15/2023
LIC809
(FAS) - (06/04)
Page:
2
of
8
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:
12/15/2023
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 LIC809C.
At 2:40pm, LPAs observed hot water measured at 137.1 degrees F. in shared clients' bathroom.
At 2:45pm, LPAs observed shared clients' bathroom mold on wall and ceiling in shower.
At 2:50pm, LPAs observed both patio screens in disrepair.
At 2:55pm, LPAs observed facility have not conducted a fire drill since 2018.
At #:55pm, LPAs observed during record review facility's MAR and medications doesn't match. MAR is not updated daily.
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 the appeal rights and this report provided.
SUPERVISORS NAME
:
Harpreet Humpal
LICENSING EVALUATOR NAME
:
Laura Hall
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/15/2023
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
12/15/2023 05:12 PM
- It Cannot Be Edited
Created By:
Laura Hall
On
12/15/2023
at
04:21 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:
12/15/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/16/2023
Plan of Correction
1
2
3
4
Administrator agreed to adjust hot water temperature to measure between 105 - 120 degrees F and submit a photo of water running to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
12/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/15/2023
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
12/15/2023 05:12 PM
- It Cannot Be Edited
Created By:
Laura Hall
On
12/15/2023
at
04:21 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:
12/15/2023
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having patio screen in repair and mold in shared upstairs bathroom shower which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/03/2024
Plan of Correction
1
2
3
4
Administrator agreed to get both patio screens repaired and mold removed from shared bathroom upstairs and submit photos to CCLD by POC date.
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in having night stands, dress, and lamps missing from bedrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/03/2024
Plan of Correction
1
2
3
4
Administrator agreed to provide items in each bedroom and submit photo 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:
12/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/15/2023
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
12/15/2023 05:12 PM
- It Cannot Be Edited
Created By:
Laura Hall
On
12/15/2023
at
04:21 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:
12/15/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(c)
Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in conducting a quarterly fire drill since 2018 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/03/2024
Plan of Correction
1
2
3
4
Administrator agreed to conduct fire drill and submit document with signatures of attendees to CCLD by POC date.
Type B
Section Cited
CCR
80070(b)(10)
Client Records
(b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having clients MAR record complete which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/03/2024
Plan of Correction
1
2
3
4
Administrator agreed to complete all client MAR records and submit a copy 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:
12/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/15/2023
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
12/15/2023 05:12 PM
- It Cannot Be Edited
Created By:
Laura Hall
On
12/15/2023
at
04:40 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:
AFU ONE VOICE CARE
FACILITY NUMBER:
079200305
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/15/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having client records current and complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/03/2024
Plan of Correction
1
2
3
4
Administrator agreed to complete all client files and submit a self-certification that to CCLD by POC date that files have been completed.
Type B
Section Cited
CCR
80066(a)
80066 Personnel Records
(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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having staff files current and complete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/03/2024
Plan of Correction
1
2
3
4
The administrator agreed to complete all staff files and submit a self-certification that all files have been completed 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:
12/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/15/2023
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
12/15/2023 05:12 PM
- It Cannot Be Edited
Created By:
Laura Hall
On
12/15/2023
at
04:44 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:
12/15/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80036(a)
80036 Licensing Fees
(a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in paying annual fees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/29/2023
Plan of Correction
1
2
3
4
Administrator agreed to pay annual fees in full by POC date and submit proof 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 days shall be maintained on the premises.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having a 7-day supply of non perishables and 2-day perishable foods for clients. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/19/2023
Plan of Correction
1
2
3
4
Administrator agreed to purchase food and submit receipts and pictures of food 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:
12/15/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/15/2023
LIC809
(FAS) - (06/04)
Page:
8
of
8