286804070-11-16-2023-21-AS-VBEI-CYN3XB-20231218173804

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286804070
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:44:04 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20231109110436

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: 4	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Angelina Manabat-Caregiver		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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FIRE CLEARANCE VIOLATIONS

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint visit, on 11/16/23 at approximately 11:00am, 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 Licensee/Administrator Charmaine Mendaros spoke with the LPA, stating they were in a training, and not able to come to the facility.

The Department obtained iinformation of the facility having serious fire clearance violations; The Department was provided fire clearance inspection documentation of 11/9/23, including pictures of the observed violations. The facility had a flip latch, and a hasp staple on the front door from the inside, these are fire clearance violations per fire code. The hallway door/fire door was observed to be held all the way open against the living room wall by the living room couch, this hallway door must be kept closed at all times, this is a fire clearance violation. Licensee is aware the hallway door is to remain closed at all times, due to choosing to not install a fire door that closes automatically if there's a fire.

Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231109110436

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/16/2023

NARRATIVE

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LPA arrived to the facility today, 11/16, and observed the hallway door all the way open, held against the the wall by the living room couch. This is a fire clearance violation, per fire inspection report of 11/9/23. LPA obtained pictures.

Based on LPA review of fire inspection on 11/9/23, obtained photos, interviews with staff, and LPA's observations on 11/16, the investigation has revealed that the allegation of "FIRE CLEARANCE VIOLATIONS" is substantiated. Due to the substantiation of the allegation, a citation, 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 will be cited today. Deficiency on LIC9099D.
This deficiency citation will have an immediate civil penalty fine assessed today, in the amount of $500, see LIC421IM.

The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Appeal Rights left, with written report, for the Administrator Charmaine Mendaros.

Exit interview conducted with caregiver Angelina Manabat, and left voice message of report findings to Licensee/Administrator Charmaine Mendaros.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231109110436

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/17/2023 Section Cited CCR 87203	1 2 3 4 5 6 7	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 was not met as evidenced by: Based on LPA review of fire inspection on 11/9/23, obtained photos	1 2 3 4 5 6 7	The facility to immediately ensure the hallway door is kept closed at all times to ensure the facility is in compliance with their fire clearance. Licensee to submit a written plan of how the facility will maintain compliance at all times with the fire clearance approved by the Local Fire Department.
	8 9 10 11 12 13 14	showing a flip latch, a hasp staple on the inside of the front door, and the hallway door being held open by the living room couch, including LPA observing on 11/16, the couch holding the hallway door open against the wall. All the above are fire clearance violations. This is an immediate risk to Health and Safety of residents in care. CP Fine assessed in te amount of $500, see LIC421IM.	8 9 10 11 12 13 14	Licensee to ensure no other locks are installed on the front door, and that the hallway door is kept closed at all times as required by fire code. Fire Department is requesting that a fire door be installed that will close automatically if there's a fire. Pease notify Licensing if you are installing a fire door, you may add this as part of your corection plan, POC due by 11/17/23.
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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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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