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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201514
Report Date: 07/03/2026
Date Signed: 07/03/2026 08:28:33 PM

Document Has Been Signed on 07/03/2026 08:28 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:WE CARE ELDERLY CARE #3FACILITY NUMBER:
079201514
ADMINISTRATOR/
DIRECTOR:		TATUM, JENAFACILITY TYPE:
740
ADDRESS:4179 BELL AVETELEPHONE:
(510) 374-4460
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 6CENSUS: 5DATE:
07/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Caregiver Julian MorrisTIME VISIT/
INSPECTION COMPLETED:
08:30 PM
NARRATIVE
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On 07/03/2026, at 08:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Required 1 Year inspection. Upon entry, the LPA explained the purpose of the visit to Caregiver Jillian Morris. Administrator (ADM) Brittany White arrived at approximately 12:30 PM and departed at approximately 5:30 PM.

The LPA toured the community inside and outside. The tour of the community included, but was not limited to, residents’ rooms, bathrooms, the kitchen, common areas, the garage, and the yards. The community was clean, appropriately furnished, and well lit. There are no bodies of water on the grounds of the community. The walkways in both the interior and exterior of the community were free from obstructions.

The residents’ bathrooms are equipped with grab bars and slip-resistant mats. At 11:36 AM, the refrigerator temperature was measured at 34 degrees and the freezer at -10 degrees Fahrenheit. At 1:47 PM, the maximum hot water temperature was measured at 113 degrees Fahrenheit. There is more than the required minimum of a 7-day supply of nonperishable foods and a 2-day supply of perishable foods on hand. The centrally stored medication cabinets were locked. At 3:06 PM, the inside temperature was measured at 68 degrees Fahrenheit in the front room.

Continued on LIC 809-C . . .
NAME OF LICENSING PROGRAM MANAGER: Lizette Francisco
NAME OF LICENSING PROGRAM ANALYST: James Sampair
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2026
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 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WE CARE ELDERLY CARE #3
FACILITY NUMBER: 079201514
VISIT DATE: 07/03/2026
NARRATIVE
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. . . Continued from LIC 809

The LPA observed the required postings in the community. Carbon monoxide and smoke detectors were operational. The fire extinguisher was last replaced on 02/02/2025. The Emergency Disaster Plan was not reviewed by the ADM. Emergency and disaster drills were not conducted for the sufficient number of staff each quarter. The first aid kit was observed to be complete, and staff dispense medications directly from the original container to residents. The liability insurance is current. An administrator is on site more than the minimum of 20 hours a week to ensure proper business operations are being conducted.

The LPA reviewed community records, 5 resident records, and 5 staff records.

1 Type A and 13 Type B citations were issued during this inspection.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 809-D. Failure to submit Proof of Corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Lizette Francisco
NAME OF LICENSING PROGRAM ANALYST: James Sampair
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 07/03/2026 08:28 PM - It Cannot Be Edited


Created By: James Sampair On 07/03/2026 at 05:58 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: WE CARE ELDERLY CARE #3
FACILITY NUMBER: 079201514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the cabinet under kitchen sink and sharps drawer in kitchen that were unlocked, which posed an immediate safety risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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2
3
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During the inspection, this was cleared when the Administrator put the sharps in the cabinet under the sink.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 07/03/2026 08:28 PM - It Cannot Be Edited


Created By: James Sampair On 07/03/2026 at 05:58 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: WE CARE ELDERLY CARE #3
FACILITY NUMBER: 079201514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above for 3 items, which poses a potential health and safety risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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3
4
The Licensee will have these repaired or replaced: hallway bathroom door mechanism, the chipped porcelain enamel on the middle of the double kitchen sink, and the missing left armrest for the chair in front room.
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 7 of the 8 rooms, which poses a potential safety risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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4
The Licensee will have adequate lighting added that uses the wall light switches to control the lights to light up the: garage, front room, and every resident room.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 07/03/2026 08:28 PM - It Cannot Be Edited


Created By: James Sampair On 07/03/2026 at 05:58 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: WE CARE ELDERLY CARE #3
FACILITY NUMBER: 079201514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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2
3
4
The Licensee purchased the PUB 475 during the visit. The Licensee will post it in accordance with the statute.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 07/03/2026 08:28 PM - It Cannot Be Edited


Created By: James Sampair On 07/03/2026 at 05:58 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: WE CARE ELDERLY CARE #3
FACILITY NUMBER: 079201514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above for 5 of 5 residents, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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2
3
4
The Licensee will increase staff at the facility to 2 staff members 365 days a year during the day and 1 night staff.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 07/03/2026 08:28 PM - It Cannot Be Edited


Created By: James Sampair On 07/03/2026 at 05:58 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: WE CARE ELDERLY CARE #3
FACILITY NUMBER: 079201514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
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: (3) 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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above for Staff S1, which posed a potential safety risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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2
3
4
The Licensee cleared the deficiency during the visit.
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 5 out of 5 residents, which poses a potential health and personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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2
3
4
The Licensee will send proof to LPA Sampair of the residents engaging in at least 3 different planned activities on at least 3 different days.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 07/03/2026 08:28 PM - It Cannot Be Edited


Created By: James Sampair On 07/03/2026 at 05:58 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: WE CARE ELDERLY CARE #3
FACILITY NUMBER: 079201514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by conducting the drill with every staff member working at this facility, which poses a potential safety risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
1
2
3
4
The Licensee will conduct drills including every staff member for the current quarter.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above because the Emergency/Disaster Plan was not reviewed by the Licensee or the Administrator, which poses a potential safety risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
1
2
3
4
The Licensee will review and sign the Emergency/Disaster Plan and make any necessary changes.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 07/03/2026 08:28 PM - It Cannot Be Edited


Created By: James Sampair On 07/03/2026 at 05:58 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: WE CARE ELDERLY CARE #3
FACILITY NUMBER: 079201514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(h)
Maintenance and Operation
(h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, because they had only 1 flashlight, which poses a potential safety risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
1
2
3
4
The Licensee will supply an adequate number of flashlights and/or battery powered lights for a 72 hour loss of electricity.
Type B
Section Cited
CCR
87461(a)(1)
Mental Condition
(a) The licensee shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1) tends to wander;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above for 1 resident R1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
1
2
3
4
The Licensee will increase staff at the facility to 2 staff members 365 days a year during the day and 1 night staff, so long as they have residents with Moderate to Severe Level of Dementia.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 10 of 12
Document Has Been Signed on 07/03/2026 08:28 PM - It Cannot Be Edited


Created By: James Sampair On 07/03/2026 at 06:03 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: WE CARE ELDERLY CARE #3
FACILITY NUMBER: 079201514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(4)
87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: (4) All facility staff and volunteers shall use gloves as a protective barrier to prevent the spread of potential infection as specified below.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview of Staff S1, the licensee did not comply with the section cited above. S1 stated that they were told "not to use so many gloves". S1 paid for their own gloves to provide adequate protection, which poses a potential health risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
1
2
3
4
The Licensee will review Section 87470 Infection Control Requirements of Title 22 personally and with all staff members, highlighting the importance of using gloves for infection control while working at the facility.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2026 08:28 PM - It Cannot Be Edited


Created By: James Sampair On 07/03/2026 at 07:36 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: WE CARE ELDERLY CARE #3
FACILITY NUMBER: 079201514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above for 1 out of 1 fire extinguishers, which poses a potential safety risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
1
2
3
4
The Licensee will purchase and mount 2A:10B:C rated fire extinguisher(s) to replace the existing one(s).
Type B
Section Cited
CCR
87632(a)
87632 Hospice Care Waiver
(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by having no hospice waiver, which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
1
2
3
4
The Licensee will apply for a hospice waiver from the Department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizette Francisco
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
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