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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601368
Report Date: 03/22/2024
Date Signed: 03/22/2024 02:01:00 PM


Document Has Been Signed on 03/22/2024 02:01 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:AGEWAY BOARDING CAREFACILITY NUMBER:
015601368
ADMINISTRATOR:DAYEH, VICTORIA & ANAFACILITY TYPE:
740
ADDRESS:2716 MEADOWLARK DRIVETELEPHONE:
(510) 475-8869
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 2DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Caregiver, Renato TisicoTIME COMPLETED:
02:05 PM
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On 03/22/2024 at 12:55PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Renato Tisico and explained the purpose of the visit. Caregiver, Zenaida Tisico was also present during visit. Administrator arrived at 1:55PM. The facility’s fire clearance was approved for 6 non-ambulatory and a hospice waiver for 2.

LPA toured facility with Renato Tisico including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are for residents and 1 bedroom is designated staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 108.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 5/23/2023. Emergency Disaster Plan was last posted on 2/06/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 2/06/2024.

At 1:10PM, LPA reviewed 2 of 2 residents records. At 1:25PM, LPA reviewed 3 of 3 staff records and 3 of 3 have current first aid training and associated to the facility. Administrator informed LPA that they notified CCLD that they plan on closing the facility in the coming months.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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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