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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603800
Report Date: 08/23/2024
Date Signed: 09/10/2024 11:58:34 AM

Document Has Been Signed on 09/10/2024 11:58 AM - 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:UNYEWAY INCFACILITY NUMBER:
374603800
ADMINISTRATOR/
DIRECTOR:		SWAFFORD, MARGIEFACILITY TYPE:
775
ADDRESS:1689 BROADWAY SUITE 106TELEPHONE:
(619) 691-6346
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 210CENSUS: 115DATE:
08/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Assistant Director Blanca VasquezTIME VISIT/
INSPECTION COMPLETED:
03:30 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) Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 08-13-2024. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Assistant Director Blanca Vasquez.

According to the facility’s license, the day program facility has a maximum capacity of two hundred ten (210) clients, of which all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, randomized review of LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of one hundred fifteen (115) clients enrolled in the day program in total, of which one hundred (100) attend program in person and fifteen (15) attend virtually. None of the enrolled clients are bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present during the inspection.

LPA reviewed records for multiple clients and multiple staff. LPA interviewed multiple clients and staff. LPA, accompanied by Licensee’s staff, also toured the interior and exterior of the facility and inspected all common areas and classrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Doors, windows, sinks, toilets, and shower were working. Extra hygiene supplies were present. The facility had sufficient space and equipment to facilitate snacks, visitation, meetings, and client activities. The facility’s ambient internal temperature was complaint at 72 F. Appliances to preserve perishable food were also all compliant in temperature: Refrigerator was 40 F, and Freezer was -8 F. Food that was present was safely stored.

Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No pools or bodies of water were observed on the premises. There were no fireplaces or open-faced heaters present. [CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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 4
Document Has Been Signed on 09/10/2024 11:58 AM - It Cannot Be Edited


Created By: Dang Nguyen On 08/23/2024 at 01:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: UNYEWAY INC
FACILITY NUMBER: 374603800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, 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
1
2
3
4
Based on LPA observation, Licensee did not ensure that cleaning solutions and other items which could pose a danger if readily avaialble to clients were stored where inaccessible to clients. This posed an immediate health and safety risk to 100 of 115 (C1 through C100) in care.
POC Due Date: 08/23/2024
Plan of Correction
1
2
3
4
During the annual inspection, LPA handed these items to day program staff, who immediately secured/locked them. This resolved the immediate risk. Licensee agreed to conduct an in-service meeting to retrain staff on what items can become hazardous in the hands of clients, and the importance of keeping them locked/secured. Licensee agreed to E-mail a copy of the training sign-in sheet to LPA, by 09-23-2024.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/10/2024 11:58 AM - It Cannot Be Edited


Created By: Dang Nguyen On 08/23/2024 at 01:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: UNYEWAY INC
FACILITY NUMBER: 374603800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA measurement with a thermometer, Licensee did not maintain controls to automatically regulate the temperature of hot water delivered to plumbing fixtures to be between 105 F and 120 F. This posed a potential health and safety risk to 100 of 115 clients (C1 through C100) in care.
POC Due Date: 09/23/2024
Plan of Correction
1
2
3
4
As of the date of deficiency issuance, Licensee had already contacted two third-party vendors who came on-site and determiend the facility’s existing boiler reached the end of its forecasted life-span and needs to be replaced. Licensee agreed to proceed with replacing its boiler and secured quotes. Licensee agreed to E-mail LPA a copy of the paid invoice showing the work is completed, by the POC due date.
Type B
Section Cited
CCR
82064(d)
Administrator -Qualifications and Duties
(d) The administrator shall receive and document a minimum of 30 clock hours of continuing education every 24 months of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and manager interview, Licensee was unable to produce documentation showing the administrator received a minimum of 30 clock hours of continuing education within the last 24 months of employment. This posed a potential health, safety, and/or personal rights risk to 115 of 115 clients (C1 through C115) in care.
POC Due Date: 09/23/2024
Plan of Correction
1
2
3
4
Licensee agreed to have the Administrator complete continuing education as is necessary to meet the regulatory requirement. Per regulation, continuing education shall include "completion of courses related to roles and responsibilities of the administrator position including, but not limited to, workshops, seminars, and academic classes." Licensee agreed to then E-mail to LPA proof that the Administrator completed 30 hours of continuing education within the last 24 months, by the POC due 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: UNYEWAY INC
FACILITY NUMBER: 374603800
VISIT DATE: 08/23/2024
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 LIC 809] Per the Licensee, no firearms or ammunition are kept at the facility. Fire detection system, carbon monoxide detectors, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE) and staff had been trained on PPE within the last twelve (12) months.

During the annual inspection, LPA saw these hazardous items inside classrooms, which were not stored inaccessible to clients (and clients were present): One (1) large hammer with metal head/face/claw, two (2) screwdrivers with metal shafts, nail polish remover, and a bottle of cleaning solution. LPA handed these items to day program staff, who immediately secured/locked them.

Where sampled/measured, hot water temperature at taps accessible to clients did not fall within the range required by regulation (which is 105 F to 120 F). Public Restroom #1 Sink was 121.3 F, Public Restroom #2 Sink 120.7 F, and Public Restroom #3 Sink was 123.1 F. Licensee’s staff attempted adjustments the facility’s boiler but were unable to lower the water temperature a few degrees. Licensee also consulted with multiple third-party vendors who came on-site and determined the facility’s existing boiler reached the end of its forecasted life-span and needs to be replaced.

During records review, LPA observed, and manager interview confirmed: Licensee was unable to furnish proof that the day program’s Administrator had completed “a minimum of 30 clock hours of continuing education” within the last 24 months, as required. [CCLD allowed Licensee ten (10) days to furnish proof.]

Three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA issued Technical Assistance (TA) regarding Colostomy Care, Postural Supports, and Restricted Health Condition Care Plans (refer to the attached LIC 9102-TA pages).

An exit interview was conducted with Vasquez, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TA pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4