015601493-3-30-2023-15-AS-LFOA-CQET2Y-20230330142130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601493
Report Date: 03/30/2023
Date Signed: 03/30/2023 02:21:39 PM

Document Has Been Signed on 03/30/2023 02:21 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:	AGEWAY BOARDING CARE #3		FACILITY NUMBER:	015601493
ADMINISTRATOR:	DAYEH, ANA		FACILITY TYPE:	740
ADDRESS:	2636 NEVADA STREET		TELEPHONE:	(510) 475-8869
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 6	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Marina Velasquez		TIME COMPLETED:	02:30 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	At around 9 am, Licensing Program Analyst (LPA) arrived unannounced to conduct annual required inspection. LPA met with staff Marina Velasquez and explained the purpose of visit. Administrator Mihael Dayeh arrived at a later time and left after a couple of hours due to a prior appointment. Mihael authorized staff Marina to sign reports. The facility has 6 residents and 2 staff observed during the visit. LPA inspected the facility inside and out including but not limited to resident room, bathrooms, dining area, garage and backyard. Hot water measured at 109 F in the common bathroom and 114.4 F in the kitchen. Chemicals were locked in the garage. Knives and other sharp objects were locked in a drawer in the kitchen. There was sufficient supply of perishable and non perishable foods. Smoke detectors and carbon monoxide were tested and observed functional. The facility temperature was observed at 72 F. There were several fire extinguishers observed that were full and last serviced on 1/13/2023. Administrator provided LPA updated liability insurance, Resident Roster, Lic 500. At around 9:45 am, LPA observed several wood planks in the backyard fence were down. At 10 am, LPA reviewed 2 resident files and 2 staff files. At 11:20 am, LPA reviewed medication and Medication Administration Record (MAR). At 1:30 pm, LPA interviewed 2 staff and 2 residents. *continuation on Lic 809C*

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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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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: AGEWAY BOARDING CARE #3	FACILITY NUMBER: 015601493
	VISIT DATE: 03/30/2023

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	Deficiency is cited per Title 22 California Code of Regulations. Please refer to LIC 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Exit interview was conducted with Marina Velasquez and Appeal Rights was provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/30/2023 02:21 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: AGEWAY BOARDING CARE #3	FACILITY NUMBER: 015601493
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(h)

Care of Persons with Dementia

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of 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. Facility failed to maintain backyard fence which poses/posed a potential health, safety or personal rights risk to persons in care. Several wood planks were observed down on the ground.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will get the fence fixed and submit to CCL photo as proof.

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.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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