075601127-4-19-2023-15-AS-PWAN-CR2QMT-20230419121804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601127
Report Date: 04/19/2023
Date Signed: 04/19/2023 12:18:28 PM

Document Has Been Signed on 04/19/2023 12:18 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	MAYON BOARD AND CARE, INC.		FACILITY NUMBER:	075601127
ADMINISTRATOR:	PANELO, ARTHUR H.		FACILITY TYPE:	740
ADDRESS:	1804 CONCORD COURT		TELEPHONE:	(925) 825-5593
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 5	DATE:	04/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Arthur Panelo, Administrator Jovito Panelo, Caregiver		TIME COMPLETED:	12:30 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	On 4/19/2023 at 9:30 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Arthur Panelo and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non ambulatory. LPA toured facility with Jovito including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119 degrees Fahrenheit. Residents’ bathroom is equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. LPA observed a purchased extinguisher but did not see a receipt attached. Administrator stated that they last purchased the fire extinguisher around 3 years ago. First aid kit was observed to be complete. Report continues on 809 C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAYON BOARD AND CARE, INC.	FACILITY NUMBER: 075601127
	VISIT DATE: 04/19/2023

NARRATIVE

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At 9:50 AM, LPA reviewed 5 residents records. At 10:15 AM, LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. At 11:40 AM, LPA reviewed a sample of resident’s medications

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/17/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiencies were observed:
-At approximately 10:45 AM LPA observed a purchased fire extinguisher without a receipt. Administrator stated they made the purchase approximately 3 years ago and will purchase a new one.

The following deficiencies were observed (see LIC 809 D) and cited from the California Code of Regulations, Title 22 and Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 04/19/2023 12:18 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MAYON BOARD AND CARE, INC.	FACILITY NUMBER: 075601127
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

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
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by not obtaining a new fire extinguisher which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed a purchased extinguisher without a receipt attached, Administrator stated they purchased it approximately 3 years ago.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Administrator will purchase a new fire extinguisher, attach receipt and provide photographic proof to CCL by POC date

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: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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