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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200753
Report Date: 03/15/2024
Date Signed: 04/25/2024 01:37:05 PM


Document Has Been Signed on 04/25/2024 01:37 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:WONDER YEARS CARE HOMEFACILITY NUMBER:
019200753
ADMINISTRATOR:NAVARRO, MICHEALFACILITY TYPE:
740
ADDRESS:2511 HENRY AVENUETELEPHONE:
(415) 942-4224
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:6CENSUS: 5DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:CHRISTINA BARNES, CAREGIVERTIME COMPLETED:
01:14 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 03/15/2024 at 9:45AM, Licensing Program Analyst (LPA) Carol Fowler, conducted an unannounced annual 1-year required inspection. LPA met with Christina Barnes, Caregiver. Rochelle Sicat, Lead Caregiver, arrived at 10:15AM and LPA explained the purpose of the visit. The facility’s fire clearance was approved for six (6) non-ambulatory and two (2) bedridden residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) bedrooms and two and a half (2.5 ) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared clients’ bathroom was measured at 107.3 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. The emergency disaster plan was last updated 12/20/2022. Fire extinguisher is missing the service tag. Fire drill last conducted 09/27/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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 5


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: WONDER YEARS CARE HOME
FACILITY NUMBER: 019200753
VISIT DATE: 03/15/2024
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
Continued from LIC809.

LPA reviewed five (5) residents files which were all complete. LPA reviewed four staff files one (1) was incomplete.

LPA observed the following deficiencies:
· At 10:25AM, LPA observed fire extinguisher is missing the service tag.
· At 10:30AM, LPA observed a staff rest area being used for staff living quarters.
· At 10:35AM, LPA observed fire extinguisher, wood planks, saw, boxes on side gate
· At 10:38AM, LPA observed unlocked storage with 3 ladders, paint, hedge cutters, tools.
· At 10:44AM, LPA observed unlocked medication in the refrigerator.
· At 10:44AM, LPA observed Administrator file incomplete.

LPA requested the following documents to be submitted to CCLD by 3/27/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance
  • Last Disaster Drill Conducted Document

Based on LPA observations and interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

*An immediate $500.00 civil penalty will be assessed on today's date for associations.*



Exit interview conducted and a copy of this report and appeal rights provided
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/25/2024 01:37 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: WONDER YEARS CARE HOME
FACILITY NUMBER: 019200753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(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 observation, the licensee did not comply with the section cited above by having items such as wood planks, fire extinguisher, boxes saw on the side yard and a unlocked storage unit which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
1
2
3
4
Administrator agreed to have items listed removed from the side yard and lock the storage and provide photos to CCLD by the POC date.
Type B
Section Cited
CCR
87307(a)(B)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on, the licensee did not comply with the section cited above by using a room in the garage for staff sleeping which poses a potential health and safety risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
1
2
3
4
Administrator agreed to remove beds, clothing and shoes and use for breakroom/storage which room has been fire cleared for. Administrator will provide photos of room once cleared.

Civil penalty of $500 is being assessed for fire clearance violation.
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) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/25/2024 01:37 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: WONDER YEARS CARE HOME
FACILITY NUMBER: 019200753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 the refrigerator which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/16/2024
Plan of Correction
1
2
3
4
Administrator will lock medication in a lockbox prior to putting it in the refrigerator. Administrator will submit picture to CCLD by POC date.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 04/25/2024 01:37 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: WONDER YEARS CARE HOME
FACILITY NUMBER: 019200753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, 3 fire extinguishers did not have any inspection tags or purchase receipt taped on cylinder to show date of purchase or when last inspected which posed a potential Health & Safety risk to residents in care.
POC Due Date: 03/22/2024
Plan of Correction
1
2
3
4
Caregiver agreed to contact contracted Fire extinguisher inspection company to have them re-inspect each fire extinguisher and place inspection tags on each fire extinguisher. Caregiver will submit to CCLD by POC due date a photo of inspection tag for each fire extinguisher.
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 having incomplete Administrator file which poses a potential health and safety risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
1
2
3
4
Administrator agreed to complete staff file and email a sample and check list to CCLD by POC.
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) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5