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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601541
Report Date: 04/10/2024
Date Signed: 04/10/2024 03:44:36 PM


Document Has Been Signed on 04/10/2024 03:44 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WAGAYA ASSISTED LIVINGFACILITY NUMBER:
075601541
ADMINISTRATOR:KATSUMOTO, MINORUFACILITY TYPE:
740
ADDRESS:905 ELM STREETTELEPHONE:
(510) 965-7678
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:6CENSUS: 6DATE:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Minoru Katsumoto, AdministratorTIME COMPLETED:
05:30 PM
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On 04/10/24 at 2:15PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced required annual inspection. LPA met with Administrator (ADM) and explained the purpose of the visit. ADM currently holds a standard certificate (6019180740) that expires 08/09/24. The facility’s fire clearance was approved for six (6) non-ambulatory residents; two (2) may have hospice waivers.

At 2:30PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas.

Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 73 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 4 staff and 5 resident files. LPA also conducted 2 staff and 2 resident interviews during visit.

Continued on next page, LIC 809-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WAGAYA ASSISTED LIVING
FACILITY NUMBER: 075601541
VISIT DATE: 04/10/2024
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No deficiencies observed during visit.

Updated copies of the following documents were collected for facility file:
 LIC500- Personnel Report
 Residents Roster
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan including infection control plans
 Evidence of Liability Insurance

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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