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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201021
Report Date: 01/26/2023
Date Signed: 01/26/2023 05:15:43 PM


Document Has Been Signed on 01/26/2023 05:15 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: 5DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Hydee Peralta, CaregiverTIME COMPLETED:
05:45 PM
NARRATIVE
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 On 1/26/2023 at 2:40pm, Licensing Program Analyst (LPA) C. Fowler and arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver, Haydee Peralta and explained the purpose of the visit. Licensee, Mila De Los Santos arrived at approximately 2:27pm.

Upon entry, LPA toured facility including but not limited to bedrooms, bathroom, kitchen, common areas, and outdoor areas. LPA 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, LPA observed visitors log and temperature logs for residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 2:46pm, LPA observed half bed rails in room #5.
-At 2:48pm, LPA observed laundry detergent, fabric softener, fabuloso accessible to residents in care located in the unlocked open door garage.
-At 2:54pm, LPA observed prescription medication in staff rest area accessible to residents in care located in the unlocked open door garage.
-At 2:59pm LPA observed softscrub and Lysol located in the bathroom under the sink.
-At 3:03pm, LPA observed a ladder, 2 unlocked sheds, wood planks, paint cans, rakes, shovels located in the backyard accessible to residents in care.

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: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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Document Has Been Signed on 01/26/2023 05:15 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: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
87309 Storage Spaces (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above by having 2 sheds in backyard not being locked, garden tools, wooden planks, paint can, rakes, shovels, accesible which poses a potential health and safety risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
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Administrator agreed to lock shed, make tools inacessible, discard paint cans, and remove wooden planks. Locking of shed, discarding and making tools and removed wooden planks and submit photo to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(A)(5)(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.
(A) Physician-prescribed orthopedic devices such as braces or casts, used for support of a weakened body part or correction of body parts, are considered postural supports.
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

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 by not having Physician orders for resident in room #5 which poses a potential health and safety risk to persons in care..
POC Due Date: 02/03/2023
Plan of Correction
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Administrator agreed to submit Physician order to CCLD no later than the 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: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/26/2023 05:15 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: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705
(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, 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: 01/27/0202
Plan of Correction
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Administrator agreed to keep the garage door locked at all times and meet with staff on the importance of working with residents with dementia submit certification 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: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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