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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200753
Report Date: 04/13/2022
Date Signed: 04/13/2022 12:42:54 PM


Document Has Been Signed on 04/13/2022 12:42 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: 4DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Dante Arienza, CaregiverTIME COMPLETED:
12:55 PM
NARRATIVE
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On 04/13/2022 at 9:50 am, Licensing Program Analysts (LPAs) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPAs met with Caregiver Dante Arienza and explained the purpose of the visit. Back-up Administrator Mia Enriquez arrived 10:05am.

Upon entry, LPA temperatures were checked by staff. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPA observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas.

During record review, LPA observed visitors log and temperature logs for residents and staff. LPA observed facility has a copy of Mitigation Plan and provided a copy to LPA. LPA observed PPE and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 10:07am, LPA observed Administrator certificate is expired.
-At 10:08am LPA observed unlocked garage door with cleaning supplies such as bleach, pine sol, laundry soap, and paint.
-At 10:19am LPA observed a unlocked shed with tools located in the backyard.


The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. 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: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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 04/13/2022 12:42 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: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)

87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Garage door unlocked and laundry soap, bleach, Pine Sol, Paint, tools, and ladder located in the garage. An unlocked shed in the backyard with gardening tools
POC Due Date: 04/14/2022
Plan of Correction
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Administrator will turn garage door knob around to lock from the outside. Administrator will also lock the shed in the back yard and provide pictures to CCLD by the POC date.
Type A
Section Cited
CCR
87355(e)(1)(2)

87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department or
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above which poses an immediate health and safety rights risk to persons in care. Unassociated staff working.
POC Due Date: 04/14/2022
Plan of Correction
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Administrator associated staff in Guardian and will send proof to CCLD no later then 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/13/2022 12:42 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: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
8740(a)(1)
(a) Administrators shall complete at least forty (40) classroom hours of continuing education during each two (2)-year certification period, including.

(1) For administrators who renew their administrator certification on or after January 1, 2003, at least eight (8) hours in subjects related to serving residents with Alzheimer's Disease and other dementias, including, but not limited to, instruction related to direct care, physical environment, and admissions procedures and assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Administrator certificate is expired as of 9/7/2020
POC Due Date: 05/13/2022
Plan of Correction
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Administrator will renew his administrator certificate and forward a copy to CCLD no later then the POC date.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
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