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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200693
Report Date: 03/28/2024
Date Signed: 03/28/2024 10:01:35 AM


Document Has Been Signed on 03/28/2024 10:01 AM - 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:A-N-D CARE HOMESFACILITY NUMBER:
019200693
ADMINISTRATOR:HAMZA, MORENIKEFACILITY TYPE:
740
ADDRESS:3284 COURTHOUSE PLACETELEPHONE:
(510) 574-9305
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:3CENSUS: 2DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee, MORENIKE HAMZATIME COMPLETED:
10:15 AM
NARRATIVE
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On 3/28/2024 at 8:30AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a required annual inspection and met with Licensee/ Administrator Morenike Hamza. . The facility’s fire clearance was approved for 3.

LPA toured facility with Licensee including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 2 bedrooms are occupied by the residents and 4 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 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 118.3 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. LPA observed a hole in the ceiling and administrator stated that there was recent water damage but that they have an appointment to get it fixed next week.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 11/01/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 11/01/2023.

At 8:40AM, LPA reviewed 2 residents records. At 9:00AM, LPA reviewed 2 staff records and 2 of 2 are associated to the facility.

Report continues on LIC 809-C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: A-N-D CARE HOMES
FACILITY NUMBER: 019200693
VISIT DATE: 03/28/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 8:40AM during file review LPA observed R1's file having an expired physicians report, unsigned personal rights, and unsigned emergency medical consent form. R1's file had an expired physicians report, and missing the emergency medical consent form.


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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/28/2024 10:01 AM - 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: A-N-D CARE HOMES
FACILITY NUMBER: 019200693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in having missing required documentation in resident files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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By POC date Administrator agrees to review and update all resident files and notify CCLD
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4