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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201095
Report Date: 09/20/2023
Date Signed: 09/20/2023 07:19:40 PM


Document Has Been Signed on 09/20/2023 07:19 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:MOONRAKER VILLA SENIOR CAREFACILITY NUMBER:
019201095
ADMINISTRATOR:AKAOSUGI, YONGFACILITY TYPE:
740
ADDRESS:22128 PROSPECT STREETTELEPHONE:
(510) 885-8837
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 5DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Yong Akaosugi/Licensee-Administrator TIME COMPLETED:
07:25 PM
NARRATIVE
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On this day, September 20, 2023, at 11:30 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Yong Akaosugi, licensee-administrator, and informed the purpose of visit. LPA also met with Dong Kim, staff.

Facility has Infection Control Plan that was submitted, and received by LPA on June 3, 2022.

LPA toured the facility inside out with the administrator. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, garage, attic storage, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the bathrooms was tested, and measured at 111.7 degrees Fahrenheit. Fire extinguisher checked, observed fully charge with tag showed serviced August 2, 2023. Facility conducts disaster drills, and records showed last conducted April 30, 2023.

LPA reviewed 2 staff and 5 residents files, and interviewed 2 staff and 2 residents. Medications checked, and compared with records and doctor's orders. Facility does not handle residents' cash resources.

LPA observed the following:
-at 12:12 pm, side fence with double lock (door knob with lock and dead bolt).
-at 12:25 pm, facility did not conduct disaster drill on July 2023.
-at 1:20 pm, staff (S2) does not have record on 4 hours training specific to postural supports, restricted health conditions, and hospice care.

...continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
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: MOONRAKER VILLA SENIOR CARE
FACILITY NUMBER: 019201095
VISIT DATE: 09/20/2023
NARRATIVE
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-at 2:50 pm, all 4 residents do not have LIC9172 Functional Capability Assessment on file.
-at 3:30 pm, R1's order of Tamsulosin is 0.4mg/daily but the medication on hand has label 0.4 mg capsule. 2 capsules daily. Medication Administration Record (MAR) showed administered 1 capsule 2x daily. LIC622 Centrally Stored Medication and Destruction Record does not show the quantity received for the 3 medications.
-at 4:00 pm, doctor's order on resident's (R2) file showed 5 medications but the medications on hand were only 3 with 2 medications dosage on labesl not consistent with the order. LIC622 Centrally Stored Medication and Destruction Record does not show the quantity received for the 3 medications.
-at 4:30 pm, resident (R3) has order of medications where 3 were not on facility's hand while one on hand has dosage different from the order. It's not clear if the 3 are no longer needed.

LPA received copies of the following current/updated documents:
1. LIC308 Designation of Facility Responsibility
2. $3M Liability Insurance certificate

Administrator to submit the following updated/current documents by October 4, 2023:
1. LIC500 Personnel Report
2. LIC610E Emergency Disaster Plan (9 pages)

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2023 07:19 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: MOONRAKER VILLA SENIOR CARE
FACILITY NUMBER: 019201095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 for staff, S2, not having the required 4 hours of training which poses a potential safety and/or personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Administrator to have the staff complete the training, and submit proof by 10/04/23.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 for not conducting drill on July 2023 which poses a potential safety risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Administrator to have drill conducted, and submit proof by 10/04/23.
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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2023 07:19 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: MOONRAKER VILLA SENIOR CARE
FACILITY NUMBER: 019201095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above for having door knob lock and dead bolt installed on the side fence which pose an immediate safety and personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Corrected.
Administrator had the locks removed while LPA was at the facility.


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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2023 07:19 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: MOONRAKER VILLA SENIOR CARE
FACILITY NUMBER: 019201095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
87465 Incidental Medical and Dental Care
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
(2) The exact dosage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above for dosages on labels of 1 of R1 and R3’s medications and 2 of R2’s medications not consistent with the doctor’s orders which pose immediate health and personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator to call the doctors of the residents to verify if dosages were changed, and obtain copies of new orders. Otherwise, obtain the medications with right dosages and administer accordingly. Proof be submitted by 9/21/23.
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above for faclity not having the 2 medications for R2 and 3 medications for R3 that were on doctor’s orders which pose an immediate health, and personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Administrator to call the residents doctor to check if the medications are no longer needed, and obtain copies of discontinued orders; otherwise, obtain the medications. Proof to be submitted by 9/21/23.
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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 09/20/2023 07:19 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: MOONRAKER VILLA SENIOR CARE
FACILITY NUMBER: 019201095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above for R1 and R2’s LIC622 incomplete. Quantity of medications received not listed/recorded. which pose potential personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Adminsitrator to complete the LIC622, and submit self-certification by 10/04/23.
Type B
Section Cited
CCR
87459(a)
87459 Functional Capabilities
(a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 4 out of 4 residents not having LIC9172 Functional Capability Assessment which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Administrator to do the assessment and submit by 10/04/23 a self-certificaition indicating it's completed.
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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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