486803996-1-12-2023-21-AS-DTOA-CMZULX-20230112144127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803996
Report Date: 01/12/2023
Date Signed: 01/12/2023 04:17:31 PM

Document Has Been Signed on 01/12/2023 04:17 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 2		FACILITY NUMBER:	486803996
ADMINISTRATOR:	MENDAROS, CHARMAINE		FACILITY TYPE:	740
ADDRESS:	1325 POTRERO CIRCLE		TELEPHONE:	(510) 388-7352
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 5	DATE:	01/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Charmaine Mendaros, Administrator		TIME COMPLETED:	02:50 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) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by lead staff, Butch Apalisoc. Administrator Charmaine Mendaros was contacted and arrived later in the visit. The facility currently provides care for 5 residents 1 of which are receiving hospice services and some of which with a of diagnosis of dementia. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with lead staff. Facility was at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 6/14/2021 at the time of the visit. Administrator will be contacting Suisun Fire Department to inspect and recharge the fire extinguisher. Smoke and carbon monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. Residents were observed to be resting after lunch in their respective bedrooms. LPA observed hospice nurse also providing weekly services to residents in care with facility following proper visitation protocols. Toxins are stored in a locked cabinet in the facility garage and under kitchen and bathroom sinks. There was a supply of hygiene products and paper products available for resident use. All residents bedrooms have lighting & appropriate furnishings. Water at faucets accessible to residents in care were measured between 113.2 and 116.0 degrees F which is within regulation. LPA conducted a sample review of staff training and found that all staff have current CPR and 1st Aid training on file. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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 3

Document Has Been Signed on 01/12/2023 04:17 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 2	FACILITY NUMBER: 486803996
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguisher requiring inspection and servicing which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2023
	Plan of Correction
1 2 3 4	Administrator agrees to contact the Suisun City Fire Department to inspect and recharge the facility fire extinguisher. Administrator to submit photo proof of corrections to CCLD by POC due date 1/24/2023.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 2	FACILITY NUMBER: 486803996
	VISIT DATE: 01/12/2023

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

Infection Control:
Facility has submitted an infection control plan for review. Posters have been placed at the front door, and facility has a station in the staff file closet near facility entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. All staff and visitors were observed to have appropriate face coverings and following facility COVID protocols.

Administrator Charmaine Mendaros's renewal Administrator Certification 6050432735 was received by the Department on 10/28/2022.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3