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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201021
Report Date: 03/14/2022
Date Signed: 03/14/2022 05:38:02 PM


Document Has Been Signed on 03/14/2022 05:38 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:M&E CAREFACILITY NUMBER:
079201021
ADMINISTRATOR:SANTOS, MARIA DELOSFACILITY TYPE:
740
ADDRESS:461 LIMERICK ROADTELEPHONE:
(510) 669-5015
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:6CENSUS: 3DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria Delos Santos, AdministratorTIME COMPLETED:
05:40 PM
NARRATIVE
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 On 03/14/2022 at 3:00 pm, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Maria Delos Santos and explained the purpose of the visit.

Upon entry, LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPAs observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitors log and temperature logs for residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPE and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 3:23pm, LPAs observed knives in a unlocked kitchen drawer.
-At 3:24pm, LPAs observed water temperature 125.4
-At 3:26pm LPAs observed prescription medication, over the counter medication, laundry detergent, fabuloso cleaner, windex, and PineSol accessible in the unlocked garage.
-At 3:28pm, LPAs observed shovels, rakes, a mattress, box spring, sledge hammer and ladder accessible in the backyard.
-At 3:31pm, LPAs observed an unlocked shed in backyard.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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 4


Document Has Been Signed on 03/14/2022 05:38 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: M&E CARE
FACILITY NUMBER: 079201021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)
87303 (e) Water...shall be maintained as follows:(2) Faucets used by residents for personal care...Hot water temperature controls shall be maintained... temperature of not less than 105 degree F (41 degree C) and not more than 120 degree...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation licensee did not comply with the section cited above by maintaining water temperature between 105 degree F and 120 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2022
Plan of Correction
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Administrator agreed to adjust temperature to measure between 105 - 120 degrees F. and submit a photo copy of temperature to CCLD by POC date. Deficiency cleared during visit.
Type A
Section Cited
CCR
87705(f)(1)
(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 which poses an immediate health, safety rights risk to persons in care.
POC Due Date: 03/15/2022
Plan of Correction
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Administrator agreed to turn the garage doorknob around to lock from the outside. To move tools into the locked garage. During visit knives were made inaccessible. To purchase a new lock for the shed and submit photo copies 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/14/2022 05:38 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: M&E CARE
FACILITY NUMBER: 079201021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:

(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee had prescription, over the counter medication and cleaning supplies such as wendex, laundry soap, PineSol, located in a unlocked garage. The licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/15/2022
Plan of Correction
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Administrator agreed to turn the garage doorknob around to lock from the outside and submit photo copies to CCLD by POC date.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4