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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200392
Report Date: 11/03/2022
Date Signed: 11/03/2022 05:35:02 PM


Document Has Been Signed on 11/03/2022 05:35 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:EMA BOARD AND CAREHOMEFACILITY NUMBER:
079200392
ADMINISTRATOR:EDWIN LIWANAGFACILITY TYPE:
740
ADDRESS:1131 ALAMO WAYTELEPHONE:
(925) 458-7098
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:10CENSUS: 4DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Merla Fernandez, CaregiverTIME COMPLETED:
05:45 PM
NARRATIVE
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On 11/3/2022 at 2:45PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Merla Fernandez, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Edwin Liwanag and was given approval for Caregiver to sign documents.

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, kitchen, and garage. 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 106.9 degrees Fahrenheit. Fire extinguisher last serviced on 9/16/2022.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the Infection Control Plan on file. LPA observed PPE and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392
VISIT DATE: 11/03/2022
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Continued from LIC809.

The following forms are to be updated and submitted to CCLD by 11/10/2022:
  • -LIC500 Personnel Report
  • -LIC308 Designation of Administrative Responsibility
  • -LIC601E Emergency Disaster Plan
  • -Facility roster

LPA observed the following deficiencies:
  • -At 2:55PM, LPA observed that S3 was not associated to the facility.
  • -At 3:03PM, LPA observed refrigerator in kitchen is inoperable.
  • -At 3:05PM, LPA observed knives in hallway closet. Closet lock was reversed. Lock was on outside of closet.
  • -At 3:10PM, LPA observed Administrator certificate expired on 10/23/22.
  • -At 3:15PM, LPA observed facility did not have a minimum of 2-day perishable and 7-day non-perishable foods for residents.
  • -At 3:30PM, LPA observed R1 and R2 does not have doctor's order for hospital bed.
  • -At 3:45PM, LPA observed S2 did not have an up-to-date first aid certificated.

The following deficiencies were 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/03/2022 05:35 PM - It Cannot Be Edited

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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)(1)
87411 Personnel Requirements – General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or

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 S3 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Licensee agreed to associate R1 to the facility and submit copy of association to CCLD by POC date.
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 knives inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Caregiver locked knives in locked kitchen pantry during visit. Deficiency cleared during visit.

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/03/2022 05:35 PM - It Cannot Be Edited

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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(32)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(32) Equipment or appropriate size and type shall be provided for the storage, preparation and service of food and for sanitizing utensils and tableware, and shall be well maintained.

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 an operable refrigerator in kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Licensee agreed to place a working refrigerator in kitchen and submit a photo to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(26) Supplies of nonperishable foods for a minimum of one week and 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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Based on observation, the licensee did not comply with the section cited above in having a 7-day non-perishable and 2-days perishables food available for residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Licensee agreed to purchase food and submit photo copies of food and receipts 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/03/2022 05:35 PM - It Cannot Be Edited

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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a certified Administrator employed at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Licensee agreed implement a plan to hire an Administrator or recertify as the Administrator, and submit plan 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 11/03/2022 05:35 PM - It Cannot Be Edited

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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having S2 first aid certified which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Licensee agreed to have S2 recertified for first aid and submit photo copy to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review), the licensee did not comply with the section cited above in having doctor orders for R1 and R2 hospital beds which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Licensee agreed to obtain doctor's orders for R1 and R2 hospital beds and submit a photo 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8