<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601400
Report Date: 09/25/2025
Date Signed: 09/25/2025 03:17:52 PM

Document Has Been Signed on 09/25/2025 03:17 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/
DIRECTOR:		GACOTE, ALEC F.FACILITY TYPE:
740
ADDRESS:2480 ALMADEN BLVD.TELEPHONE:
(510) 429-8630
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 3DATE:
09/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH: Maria Linda Erolin, Licensee TIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/25/2025 at 10:45 am Licensing Program Analysts (LPA) K. Nguyen and P. Manalo arrived unannounced to conduct the 1-year annual requirement. LPA was greeted by care staff, Juan Pao Guintu and explained the purpose of the visit. LPAs spoke with Licensee Maria Linda Erolin and explained the purpose of the visit. Licensee arrived at 11:45 AM.

LPAs 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 a sufficient supply of perishable and nonperishable foods. Towels, linen, and warm blankets were observed to be sufficient. Bathrooms and shower rooms have grab bars, a nonslip mat, and hygiene products. Smoke detectors and carbon monoxide were observed operational in the facility hallway. Hot water in the shared bathroom measured at 112.5°F. Fire extinguisher in the kitchen appears full and was last serviced on 07/07/2025. The first aid kit was observed to be complete. Emergency Drills was last conducted on 07/12/2025.

LPA reviewed 3 resident files and 3 staff files.

LPA reviewed the medication and log.

Report continued to LIC809c...

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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 8
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 8
Document Has Been Signed on 09/25/2025 03:17 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/25/2025 at 11:54 AM
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: A AND M BOARD&CARE,INNOVATIVE ASSIS.HOME FOR ELDER
FACILITY NUMBER: 015601400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(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 observations, the licensee did not comply with the section cited above by having foul odor coming in Room # 2, hoyer lift in the living room, two hoyer lift in the backyard, flies all around the facility, fridge and freezer not clean, etc. which poses a potential health and safety risk to persons in care.
POC Due Date: 10/02/2025
Plan of Correction
1
2
3
4
Staff agrees to removed hoyer lift, organize fridge/ freezer, and clean resident room.
Type B
Section Cited
CCR
87411(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 not having a TB test for S2 which poses a potential safety risk to persons in care.
POC Due Date: 10/02/2025
Plan of Correction
1
2
3
4
Administrator will obtain a TB test for S1 and send results 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/25/2025 03:17 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/25/2025 at 02:25 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: A AND M BOARD&CARE,INNOVATIVE ASSIS.HOME FOR ELDER
FACILITY NUMBER: 015601400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)
General Food Service Requirements
(b) The following food service requirements shall apply:

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 by having expired food in the refrigerator and spoiled/molded fruits in the basket which poses an immediate safety risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
1
2
3
4
Administrator agrees to self-certify the regulation, throw away the expired food, and send proof to CCLD by POC date.
Type A
Section Cited
CCR
87309(c)
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

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 by having unlocked medication in resident's room and medication in the staff lounge area which posed an immediate safety risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
1
2
3
4
Administrator agrees to self-certify the regulation with staff and send proof 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 09/25/2025 03:17 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/25/2025 at 02:25 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: A AND M BOARD&CARE,INNOVATIVE ASSIS.HOME FOR ELDER
FACILITY NUMBER: 015601400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 not having a valid CPR certificate for S1 which poses a potential safety risk to persons in care.
POC Due Date: 10/02/2025
Plan of Correction
1
2
3
4
Administrator will obtain a CPR certification for S1 and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

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 not having an updated medical assessment for 3 of 3 residents which poses a potential health and personal risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
1
2
3
4
Administrator agrees to obtain a new medical assessment for all 3 residents and send proof 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
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: 09/25/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continue from LIC809-C...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/02/2025:

LIC 500 Personnel Report

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING THE VISIT:

LPAs observed medication left on the table in the staff breakroom and in the residents' room.

LPAs observed fruit flies in the dining area, on the countertop, and on the walls.

LPAs observed expired food in the refrigerator and spoiled/molded fruits in the basket.

LPAs conducted a file review. S2 does not have TB on record

LPAs conducted a file review. S2 does not have CPR on record

LPAs conducted residents' files; 3 out of 3 do not have an updated assessment on record

LPAs observed foul odor coming in Room # 2, hoyer lift in the living room, two hoyer lift in the backyard, flies all around the facility, fridge and freezer not clean, etc.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. A $250 civil penalty is assessed for repeat violation within 12 12-month period of section 87555(b). Failure to submit proof of corrections by the plan of correction due date may result in additional civil penalties.

Exit interview conducted. Appeal Rights, LIC421FC Civil penalty assessment, LIC9098 Proof of Correction form and copy of this report provided.

Exit interview conducted. Appeal Rights and a copy of this report are provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
Page: 8 of 8