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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 03:44:19 PM


Document Has Been Signed on 10/08/2024 03:44 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Linda Erolin, Licensee TIME COMPLETED:
10:30 AM
NARRATIVE
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On 10/8/2024 at 10:0AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a 1 year annual requirement visit. LPA met with Care staff and explained the purpose of the visit and later Licensee, Maria Linda Erolin later arrived.

When entering the facility LPA observed an individual (visitor) in the kitchen prepping food for residents. LPA interview S1, S2, and S3 stated the individual stay at the facility helping. LPA confirmed that the individual, and reviewing Guardian system the individual is not background clear.

Civil penalty of $100 is being assessed.

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

Exit interview conducted. A copy of this report, civil penalty, and appeal rights 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
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 10/08/2024 03:44 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2024
Section Cited
CCR
87411(g)(3)

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Personnel Requirements - General. Request and be approved for a background, and criminal record exemption... This requirement is not met as evidence by:
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Facility has agreed to obtain background and criminal record for any induvial that are assisting residents moving forward.
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Based on record review, licensee did not comply with the section cited above by not having background, and criminal record which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $100 is being assessed.

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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) 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)
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