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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079200392
Report Date:
10/26/2023
Date Signed:
10/26/2023 05:31:27 PM
Document Has Been Signed on
10/26/2023 05:31 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:
EMA BOARD AND CAREHOME
FACILITY NUMBER:
079200392
ADMINISTRATOR:
EDWIN LIWANAG
FACILITY TYPE:
740
ADDRESS:
1131 ALAMO WAY
TELEPHONE:
(925) 458-7098
CITY:
PITTSBURG
STATE:
CA
ZIP CODE:
94565
CAPACITY:
10
CENSUS:
6
DATE:
10/26/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:30 PM
MET WITH:
Merla Fernandez, Caregiver
TIME COMPLETED:
05:40 PM
NARRATIVE
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On 10/26/2023 at 1:30PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Merla Fernandez, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator Edwin Liwanag via telephone. The Administrator currently holds a certificate (#6020847740) that expires on 10/23/2024. The facility’s fire clearance was approved for eight (8) non-ambulatory and two (2) bedridden residents.
LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) total bedrooms which and three (3) bathrooms. One (1) bedrooms is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. No bodies of water observed. A comfortable temperature is maintained at 67 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 102.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.
Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/16/2022. Emergency Disaster Plan was last posted on 02/18/2021. First aid kit was observed to be complete. Fire drill was last conducted on 03/16/2022.
Continued on LIC809.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
10/26/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
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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:
EMA BOARD AND CAREHOME
FACILITY NUMBER:
079200392
VISIT DATE:
10/26/2023
NARRATIVE
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Continued from LIC809.
Four (4) staff records were reviewed and none have first aid certification. All six (6) resident records were reviewed and four (4) of six (6) did not have a current appraisal needs and services plan.
LPA observed the following deficiencies:
At 1:40PM, LPA observed knives and 2 pair of scissors sitting in container on kitchen counter.
At 1:50PM, LPA observed there was not a 7-day of non-perishables and 2-day perishable foods available for the residents.
At 1:55PM, LPA observed resident sitting in garage where Tide detergent, Clorox, and Lysol disinfect was accessible.
At 2:10PM, LPA observed bathroom between bedrooms #6 and #4 door was being blocked in bedroom #6 by resident's bed, and staff using bedroom #4 to get to bathroom for staff use only.
At 2:15PM, LPA observed oxygen tanks not on stands in R6's room.
At 2:25PM, LA observed during record review that R1 and R6 was recently hospitalized and Administrator did not submit an incident report.
At 2:35PM, LPA observed during record review that four (4) of six (6) residents did not have a current appraisal needs and services plan.
At 2:40PM, LPA observed during record review that R1 and R6 did not have a home health agreement available for review.
At 3:45PM, LPA observed during record review that S3 did not have a file available to review.
At 3:50PM, LPA observed during record review that none of the staff have a first aid certification.
Continued on LIC809C.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2023
LIC809
(FAS) - (06/04)
Page:
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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:
EMA BOARD AND CAREHOME
FACILITY NUMBER:
079200392
VISIT DATE:
10/26/2023
NARRATIVE
1
2
3
4
5
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Continued from LIC809C.
LPA requested the following documents to be submitted to CCLD by 11/2/2023.
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Resident roster
The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. A copy of the appeal rights and this report and appeal rights provided.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2023
LIC809
(FAS) - (06/04)
Page:
3
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Document Has Been Signed on
10/26/2023 05:31 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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
EMA BOARD AND CAREHOME
FACILITY NUMBER:
079200392
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/26/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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 scissors, knives, detergents and disinfectants accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/27/2023
Plan of Correction
1
2
3
4
Administrator agreed to lock away all items and submit photo to CCLD 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
10/26/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2023
LIC809
(FAS) - (06/04)
Page:
4
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8
Document Has Been Signed on
10/26/2023 05:31 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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
EMA BOARD AND CAREHOME
FACILITY NUMBER:
079200392
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/26/2023
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 observation an record review, the licensee did not comply with the section cited above in having all staff with first aid and/or CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/08/2023
Plan of Correction
1
2
3
4
Administrator agreed to get all staff first aid certified and submit certificates to CCLD by POC date.
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 observation and record review, the licensee did not comply with the section cited above in having a completed file for S3 available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/08/2023
Plan of Correction
1
2
3
4
Administrator agreed to complete a file for S3 and submit self-certification that the file has been completed to CCLD by POC 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
10/26/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2023
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
10/26/2023 05:31 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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
EMA BOARD AND CAREHOME
FACILITY NUMBER:
079200392
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/26/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having a current appraisal needs and services plan for all residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/08/2023
Plan of Correction
1
2
3
4
Administrator agreed to submit self-certification that a current appraisal needs and services plan has been created for each resident and submit a self-certification to CCLD by POC date.
Type B
Section Cited
CCR
87609(b)(4)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having an agreement with the home health agency for review for R1 and R6 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/08/2023
Plan of Correction
1
2
3
4
Administrator agreed to obtain an agreement or care plan from the home health for R1 and R6 and submit plan to CCLD by POC 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
10/26/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2023
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
10/26/2023 05:31 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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
EMA BOARD AND CAREHOME
FACILITY NUMBER:
079200392
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/26/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(E)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.
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 oxygen tanks secured to the wall or on a stand which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/08/2023
Plan of Correction
1
2
3
4
Administrator agreed to place oxygen tanks on a stand or secure them to the wall and submit photo to CCLD by POC date.
Type B
Section Cited
CCR
87307(a)(2)(C)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
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 in using the bedroom as a passageway to the bathroom for staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/08/2023
Plan of Correction
1
2
3
4
Administrator agreed to submit self-certification that staff will not use bedroom as a passageway to the bathroom, and that the bathroom can be used by the residents, to CCLD by POC 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
10/26/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2023
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
10/26/2023 05:31 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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
EMA BOARD AND CAREHOME
FACILITY NUMBER:
079200392
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/26/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(26)
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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 7-day non perishable and 2-day perishable food for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/08/2023
Plan of Correction
1
2
3
4
Administrator agreed to purchase food and submit photos and receipts to CCLD by POC date.
Type B
Section Cited
CCR
87211(a)(1)
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in reporting R1 and R6 hospitalization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/08/2023
Plan of Correction
1
2
3
4
Administrator agreed to submit LIC624 for R1 and R6 to CCLD by POC 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:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
10/26/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2023
LIC809
(FAS) - (06/04)
Page:
8
of
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