286804070-10-2-2023-21-AS-DALO-CW8VPH-20231002163648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804070
Report Date: 10/02/2023
Date Signed: 10/02/2023 04:37:01 PM

Document Has Been Signed on 10/02/2023 04:37 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	AGING IN THE BAY 3		FACILITY NUMBER:	286804070
ADMINISTRATOR:	MENDAROS, CHARMAINE		FACILITY TYPE:	740
ADDRESS:	1088 DONALDSON WAY		TELEPHONE:	(510) 388-7352
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY:	6	CENSUS: 5	DATE:	10/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Angelina Manabat-Caregiver		TIME COMPLETED:	04:50 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	Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 10/2/23 at approximately 10:20am, and met with caregivers Angelina Manabat, and Romeo Manabat. Caregiver Angelina contacted the Administrator and notified them that the LPA was at the facility. The Administrator Charmaine Mendaros arrived within an hour of being notified that the LPA was at the facility. Facility has an infection control plan as required. Facility has an emergency and disaster plan as required. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Fire clearance is approved for one (1) ambulatory, and five (5) non-ambulatory, of which three (3) may be bedridden; 1 bedridden in room #5, 2 bedridden in room #4, 1 non-ambulatory in room #2, 1 non-ambulatory in room #3, and 1 ambulatory in room #1. Fire extinguisher expires soon, one(1) scheduled to be serviced and tagged this Thursday,10/5/23. Facility was found to be clean, orderly,and at a comfortable temperature with all exits free from obstruction. Hot water was checked at 117.F which is within regulation. Medications were stored and locked making them inaccessible to residents. All toxins and cleaners were stored in locked cabinets, and inaccessible to residents in care. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. LPA observed sufficient supply of food, perishable and non-perishable. The LPA reviewed five (5) resident files. LPA reviewed five(5) of five(5) staff files. All five (5) staff have criminal record clearance as required. Per record reviews, three (3) staff are associated as required. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGING IN THE BAY 3	FACILITY NUMBER: 286804070
	VISIT DATE: 10/02/2023

NARRATIVE

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LPA is requesting the following documents be updated and submitted by 11/2/2023:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Copy of LIC400 Handling of Client Cash Resources, complete form and submit
Copy of Surety Bond (if handling resident cash)
Copy of Current Liability Insurance
Copy of current Administrator Certificate

Per LPA's file reviews, staff lack current First Aid, S2, S3, and S4. This deficiency will be cited, Personal Requirements-General 87411(c )1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross, see LIC809D.

Per LPA's file reviews, direct care staff lack current CPR certification as required, S2, S3, S4, and S5. This deficiency will be cited, H&S 1569.618(c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR, see LIC809D.

Per LPA's file reviews, staff S4, and S5 are not associated to the facility as required. This deficiency will be cited, Criminal Record Clearance 87355(e)(3) Request a transfer of a criminal record clearance as specified in Section 87355(c), see LIC809D.

Per LPA's file review, staff, S2, S3, S4, & S5, files were found to be incomplete. This deficiency will be cited, Personnel Records 87412(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain all required records, see LIC809D.

Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/02/2023 04:37 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGING IN THE BAY 3	FACILITY NUMBER: 286804070
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's file reviews, direct care staff lack current CPR certification as required, S2, S3, S4, and S5, the licensee did not comply with the section cited above in [4] out of [5] staff which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that staff have CPR as required/needed; There must be one staff on each shift that has CPR certification at all times. Submit staff, S2, S3, S4, and S5, copies of obtained CPR certification. POC due 10/3/23.

Type A

Section Cited

CCR

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's file reviews, staff S4, and S5 are not associated to the facility as required], the licensee did not comply with the section cited above in [2] out of 5() staff which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that staff are associated as required; Submit all required paperwork to the licensing office to have S4 & S5 associated to the facility. POC due 10/3/23.

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/02/2023 04:37 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGING IN THE BAY 3	FACILITY NUMBER: 286804070
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's file reviews, staff lack current First Aid, S2, S3, and S4, the licensee did not comply with the section cited above in [4] out of [5] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that staff have First Aid as required; All direct care staff must have current first aid certification. Submit staff, S2, S3, and S4, copies of obtained First Aid certification. POC due 10/3/23.

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/02/2023 04:37 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGING IN THE BAY 3	FACILITY NUMBER: 286804070
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(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 LPA's file review, staff, S2, S3, S4, & S5, files were found to be incomplete, the licensee did not comply with the section cited above in [4] out of [5] staff files, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	Licensee to ensure all staff have complete files with all required documents. Licensee to ensure all records are made complete and submit written self-certification to this, that all staff files are complete and available for review. POC due 10/31/23.

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/02/2023 04:37 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGING IN THE BAY 3	FACILITY NUMBER: 286804070
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(1)

Other Provisions

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's file review, staff, S2, S3, S4, and S5, have proof of required 40/20 hrs of required annual training., the licensee did not comply with the section cited above in [4] out of [5] staff record reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	Licensee to ensure all staff , S2, S3, S4, and S5, obtain required initial 40 hour training and annual 20 hour training as required by H&S; Submit proof of required trainings having been completed by POC due date of 11/16/23.

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/02/2023 04:37 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGING IN THE BAY 3	FACILITY NUMBER: 286804070
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.69(a)(2)

Personnel Records/Staff Training -1569.69(a)(2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation staff S2, S3, S4, and S5 lack medication training as required, the licensee did not comply with the section cited above in [4] out of 5] staff, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2023
	Plan of Correction
1 2 3 4	Licensee to ensure all staff obtain required medication training per Health & Safety 1569.69; Submit proof of all staff having obtained required medication training by 10/9/23. Submit plan of correction in correcting this deficiency by POC due date of 10/3/23.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGING IN THE BAY 3	FACILITY NUMBER: 286804070
	VISIT DATE: 10/02/2023

NARRATIVE

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Per LPA's file review, staff, S2, S3, S4, and S5, have proof of required 40/20 hrs of required annual training. This deficiency will be cited, H&S 1569.625(b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training initially, and 20 hours annually, see LIC09D.

Per LPA's review of files, staff S2, S3, S4, and S5 lack medication training as required, his deficiency will be cited, Personnel Records/Staff Training -1569.69(a)(2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. . Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties being assessed.
Exit interview conducted with the Administrator Charmaine Mendaros.
Appeal rights were provided.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

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