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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201384
Report Date: 12/03/2024
Date Signed: 12/03/2024 01:09:19 PM

Document Has Been Signed on 12/03/2024 01:09 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ECOLUX ASSISTED LIVINGFACILITY NUMBER:
079201384
ADMINISTRATOR/
DIRECTOR:		VERMA, BHARATFACILITY TYPE:
740
ADDRESS:158 MIRA VISTA DRTELEPHONE:
(650) 665-0894
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 2DATE:
12/03/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Mylyn Rios, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:19 PM
NARRATIVE
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On 12/03/2024 at 10:30AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a post licensing inspection. LPA met with caregiver, Mylyn Rios who contacted the Administrator Bharat Verma via telephone. LPA advised Administrator the purpose of visit. Administrator gave authorization for Mylyn to sign the report.

Upon entry, LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area, and backyard. Facility has a 2-day supply of perishable and 7-day non-perishable food supplies. Hot water temperature was measured at 116.6 degrees F in residents’ shared bathroom. A comfortable temperature maintained at 69 degrees F for residents in care. Grab bars and non-skid materials were observed in the residents’ bathrooms. Extra linens and towels were observed in the hallway closet. Carbon monoxide and smoke detector were observed. There are no bodies of water observed. Medications were centrally stored and lock in a cabinet. Fire extinguisher was observed to be full.


At 11:12AM, LPA observed unlocked WD-40 multi use product under kitchen cabinet.
At 11:19AM, LPA observed expired food in pantry located in the kitchen.
At 11:57PM, LPA observed during file review S3 was not associated to facility.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided to Mylyn Rios.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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Document Has Been Signed on 12/03/2024 01:09 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 12/03/2024 at 12:24 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: ECOLUX ASSISTED LIVING
FACILITY NUMBER: 079201384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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.

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 one (1) can of WD-40 multi use product under an unlocked cabinet in kitchen which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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Caregiver immediately removed WD-40 multi use product and placed it in a locked cabinet during visit. Deficiency cleared.
Type A
Section Cited
CCR
87355(a)(2)
87355 Criminal Record Clearance

e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) 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, per guardian S3 is in process status which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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Administrator agreed to submit and LIC9182 and a copy of S3's identification to associate or associated S3's to facility via guardian 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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/03/2024 01:09 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 12/03/2024 at 12:24 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: ECOLUX ASSISTED LIVING
FACILITY NUMBER: 079201384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 twenty five (25) expired food products located in the kitchen pantry which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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Caregiver immediately disposed of expired food during visit. Deficiency cleared.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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