075601451-1-5-2024-15-AS-AGOZ-CZ7V4T-20240105150652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601451
Report Date: 01/05/2024
Date Signed: 01/05/2024 03:07:02 PM

Document Has Been Signed on 01/05/2024 03:07 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	KARO MINA CARE HOME		FACILITY NUMBER:	075601451
ADMINISTRATOR:	EWEDA, MONA		FACILITY TYPE:	740
ADDRESS:	2866 LARAMIE AVENUE		TELEPHONE:	(925) 551-8263
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 3	DATE:	01/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Mona Eweda		TIME COMPLETED:	03:15 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 01/05/2024 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival, LPA was greeted by Caregiver Pauline Fearon Mitchell. Licensee arrived at 10:00 AM. LPA met with Licensee, Mona Eweda and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory. LPA toured facility with Mona including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 69 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 109.4 degrees Fahrenheit. Residents’ bathrooms are 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 detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/20/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 12/10/2023. Report continues on LIC809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KARO MINA CARE HOME	FACILITY NUMBER: 075601451
	VISIT DATE: 01/05/2024

NARRATIVE

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At 12:00PM LPA reviewed 3 of 3 residents records. At 12:20 PM, LPA reviewed 3 staff records. ALl staff are associated to the facility.

The following Deficiencies were observed:

At 9:00AM When LPA arrived only one staff was on duty and staff does not posses the required training required by CCLD.
At 12:30PM During file review LPA observed that there was no file for Pauline Fearon Mitchell and that all files were incomplete and missing documents for other staff (criminal record statement, LIC 501)
At 1:30PM During file review LPA observed that no staff has valid first aid or CPR.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/19/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

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

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

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/05/2024 03:07 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KARO MINA CARE HOME	FACILITY NUMBER: 075601451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 record review, the licensee did not comply with the section cited above in having expired cpr/first aid for all staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	By POC date administrator agrees to get all staff first aid and CPR certified and self certify to CCLD

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) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/05/2024 03:07 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KARO MINA CARE HOME	FACILITY NUMBER: 075601451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(a)

Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having untrained staff working solo with residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	By POC date administrator agrees to either train new care staff or reschedule trained staff to be on the premises at all times and self certify to CCLD.

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) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 01/05/2024 03:07 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KARO MINA CARE HOME	FACILITY NUMBER: 075601451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/05/2024

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 record review, the licensee did not comply with the section cited above in 4 out of 4 persons not having complete or missing personnel files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	By POC date administrator agrees to review and complete all staff files and self certify to CCLD.

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) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

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