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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200305
Report Date: 12/20/2024
Date Signed: 12/20/2024 05:20:26 PM

Document Has Been Signed on 12/20/2024 05:20 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/
DIRECTOR:		AFU, ANAFACILITY TYPE:
735
ADDRESS:180 OAKPOINT COURTTELEPHONE:
(925) 457-7460
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Ana Afu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 12/20/2024 at 2:15pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. Administrator called and spoke with LPA via telephone and LPA explained the reason for the visit. Administrator, Ana Afu, arrived at 3:10pm. 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 are occupied 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. Hot water temperature in the shared clients’ bathroom was measured at 131.8 degrees Fahrenheit. All toilets were in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 12/29/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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: AFU ONE VOICE CARE
FACILITY NUMBER: 079200305
VISIT DATE: 12/20/2024
NARRATIVE
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Continued from LIC809.

LPA reviewed all three (3) client files and all are incomplete. Facility was missing two (2) client files. There were not any staff files to review.

The following forms to be updated and submitted to CCLD by 12/30/2024:
  • LIC610D Emergency disaster plan (all 9 pages)
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • Client roster


LPA observed the following deficiencies:
  • At 2:30pm, LPA observed clients being dropped of to facility and left unsupervised.
  • At 2:40pm, LPA observed facility did not have a minimum supply of 7-day non-perishable and two day perishable foods for clients.
  • At 2:43pm, LPA observed flip door lock on front door.
  • At 2:57pm, LPA observed 2 bedrooms did not have night stands, 1 bedroom did not have a chest of drawers, two (2) bedrooms need a lamp, one (1) chest of drawers needs handles and knob fixed.
  • At 3:10pm, LPA observed a microwave, love seat, couch, chair, and a wooden pallet in the back yard.
  • At 3:20pm, LPA observed facility had not conducted a quarterly fire drill.
  • At 3:30pm, LPA observed facility did not have any staff files.
  • At 3:30pm, LPA observed the three (3) clients files were incomplete and two (2) client files were not available for review.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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: AFU ONE VOICE CARE
FACILITY NUMBER: 079200305
VISIT DATE: 12/20/2024
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Continued from LIC809C.

*An immediate civil penalty of $500.00 is assessed on today's date for supervision*

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: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/20/2024 05:20 PM - It Cannot Be Edited


Created By: Laura Hall On 12/20/2024 at 04:35 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: AFU ONE VOICE CARE
FACILITY NUMBER: 079200305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having a couch, love seat, microwave, etc in back yard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
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Administrator agreed to have all items removed and submit photo 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
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having night stands, chest of drawers, and lamps for clients bedrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
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2
3
4
Administrator agreed to purchase lamps, chest of drawers, and night stands for clients bedrooms 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: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


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Document Has Been Signed on 12/20/2024 05:20 PM - It Cannot Be Edited


Created By: Laura Hall On 12/20/2024 at 04:35 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: AFU ONE VOICE CARE
FACILITY NUMBER: 079200305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(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
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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: 12/23/2024
Plan of Correction
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Administrator agreed to purchase food and submit a copy of the receipt and picture of food to CCLD by POC date.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 conducting a quarterly fire drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Administrator agreed to conduct a fire drill and submit documentation 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: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


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Document Has Been Signed on 12/20/2024 05:20 PM - It Cannot Be Edited


Created By: Laura Hall On 12/20/2024 at 04:41 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: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1548(c)(3)
§1548 Civil penalties; regulations setting forth appeal procedures for deficiencies
(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:

(3) Absence of supervision, as required by statute or regulation.

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 leaving clients unsupervised at facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2024
Plan of Correction
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S2 arrived at the facility approximately 2:50pm. Deficiency cleared during visit.
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: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/20/2024 05:20 PM - It Cannot Be Edited


Created By: Laura Hall On 12/20/2024 at 04:45 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: 12/20/2024

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
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having client records complete and available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
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Administrator agreed to complete all client records and submit self certification that records have been completed to CCLD by POC date.
Type B
Section Cited
CCR
80066
(b) 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
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having staff records available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
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2
3
4
Administrator agreed to complete all staff files and submit self certification that records were 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: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


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