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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601400
Report Date: 10/08/2024
Date Signed: 10/08/2024 05:24:42 PM


Document Has Been Signed on 10/08/2024 05:24 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:A AND M BOARD&CARE,INNOVATIVE ASSIS.HOME FOR ELDERFACILITY NUMBER:
015601400
ADMINISTRATOR:GACOTE, ALEC F.FACILITY TYPE:
740
ADDRESS:2480 ALMADEN BLVD.TELEPHONE:
(510) 429-8630
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maria Linda Erolin, Licensee TIME COMPLETED:
05:45 PM
NARRATIVE
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On 10/8/2024 at 10:30 am Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1-year annual requirement. LPA meet with was greeted by care staff, Teresita Dimain and explained the purpose of the visit. LPA spoke with Licensee Maria Linda Erolin and explained the purpose of the visit and arrived at 2pm.

LPA with Licensee inspected the facility inside and out including but not limited to resident rooms, bathrooms, living room, kitchen, dining area and backyard. Hallways and passageways were observed free of obstruction.


There was sufficient supply of perishable and non perishable foods. Towels, linen and warm blankets were observed sufficient. Bath/shower rooms have grab bars, non skid mat and hygiene products. Smoke detectors and carbon monoxide were observed operational. Fire extinguisher in the kitchen appears full and was last serviced on 1/29/24. First aid kit was observed complete.

LPA reviewed 5 resident files and 6 staff files.
LPA reviewed medication and log.

Report continued on LIC809c...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
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 10/08/2024 05:24 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: A AND M BOARD&CARE,INNOVATIVE ASSIS.HOME FOR ELDER
FACILITY NUMBER: 015601400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation hot water temperature measured at 140.2-degree Fahrenheit, the licensee did not comply with the section cited above in, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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LIcensee agree to fix water temp. and send photo of hot water temp under 125 degree F to CCLD by POC date.
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation medication were left in the Ziplock bag on the couch, and mediation in resident room 1 is on the counter., the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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LIcensee agree to remove medication from residents room, and lock them and submit photo 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) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 10/08/2024 05:24 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: A AND M BOARD&CARE,INNOVATIVE ASSIS.HOME FOR ELDER
FACILITY NUMBER: 015601400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 LPA observation expired food in the refrigerator and molded fruits in the basket, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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LIcensee agree to remove all expired food/fruti from refrigerator and basket, and submit submit photo to CCLD by POC date.
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation multiples cockroach in the kitchen cabinet, countertop, and in the garage food pantry, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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LIcensee agree to contact professional to consult on how to eleminate the roaches. Licensee will send confirmation of communiation and photo roaches free 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) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: A AND M BOARD&CARE,INNOVATIVE ASSIS.HOME FOR ELDER
FACILITY NUMBER: 015601400
VISIT DATE: 10/08/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
· LPA observed medication left in the Ziplock bag on the couch, and mediation in resident room 1 is on the counter.
· LPA observed hot water temperature measured at 140.2-degree Fahrenheit.
· LPA observed multiples cockroach in the kitchen cabinet, countertop, and in the garage food pantry.
· LPA observed expired food in the refrigerator and molded fruits in the basket.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4