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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200937
Report Date: 09/14/2023
Date Signed: 09/14/2023 04:03:00 PM


Document Has Been Signed on 09/14/2023 04:03 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:AGING IN THE BAYFACILITY NUMBER:
079200937
ADMINISTRATOR:CHARMAINE MENDAROSFACILITY TYPE:
740
ADDRESS:4617 HIDDEN GLEN DRTELEPHONE:
(925) 206-4770
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 4DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Charmaine Mendaros, Administrator
Xavier Carabbacan, Staff		TIME COMPLETED:
05:30 PM
NARRATIVE
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On 09/14/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S1) and spoke with administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with staff (S1, ADM).

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 sanitizer 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 74 deg F. Hot water temperature was measured at 117 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. Fire extinguisher was observed fully charged. LPA reviewed 3 staff and 4 resident files. LPA also conducted 2 staff and 2 resident interviews during visit.

The following deficiencies were observed during visit:
  • Two expired fire extinguishers (purchase date 10/02/19)
  • 4 open trash bins in bathrooms & bedrooms

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: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
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


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: AGING IN THE BAY
FACILITY NUMBER: 079200937
VISIT DATE: 09/14/2023
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Updated copies of the following documents were collected for facility file:
 LIC500- Personnel Report
 Resident Roster
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan including infection control plans
 Evidence of Liability Insurance


Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proofs of correction (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights 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: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/14/2023 04:03 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: AGING IN THE BAY
FACILITY NUMBER: 079200937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203


This requirement is not met as evidenced by:
Deficient Practice Statement
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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 was not met as evidenced by expired fire extinguishers which posed a potential health & safety risk to residents in care.

POC Due Date: 09/29/2023
Plan of Correction
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By POC due date, Administrator agreed to purchase new fire extinguishers to replace the expired ones and submit copies of receipts to CCL. Administrator understands that fire extinguishers need to be inspected every year for compliance with fire safety requirements.
Type B
Section Cited
CCR
87303(f)(3)


This requirement is not met as evidenced by:
Deficient Practice Statement
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All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof... This requirement was not met as evidenced by open trash bins in bathrooms & bedrooms which posed a potential health & safety risk to residents in care.
POC Due Date: 09/29/2023
Plan of Correction
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By POC due date, Administrator agreed to replace all open trash bins with trash bins with foot operated lids in compliance with Title 22 Section 87303 (f)(3) and submit copies of receipts to CCL.
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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