079201021-1-10-2024-15-AS-CFOR-CZCSHC-20240110125319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201021
Report Date: 01/10/2024
Date Signed: 01/10/2024 12:53:37 PM

Document Has Been Signed on 01/10/2024 12:53 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:	M&E CARE		FACILITY NUMBER:	079201021
ADMINISTRATOR:	SANTOS, MARIA DELOS		FACILITY TYPE:	740
ADDRESS:	461 LIMERICK ROAD		TELEPHONE:	(510) 669-5015
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY:	6	CENSUS: 4	DATE:	01/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	MARIA DELOS SANTOS ADMINISTRATOR		TIME COMPLETED:	01:15 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 01/10/2024 at 9:30 AM Licensing Program Analyst (LPAs) Carol Fowler and Tonica Syess-Gibson conducted an unannounced 1-Year Required inspection. LPAs met with Maria Delos Santos, Administrator, and explained the purpose of the visit. The Administrator currently holds a certificate (#6020874740) that expires on 10/14/2024. The facility’s fire clearance was approved for four (4) non-ambulatory and two (2) bedridden residents. LPAs toured the facility with Administrator including but not limited to bedrooms, bathroom, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by staff, and one (1) bathroom. No bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPAs 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 108.8 degrees Fahrenheit. Residents’ bathroom is equipped with grab bars and non-skid mat. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/27/2023. Emergency Disaster Plan was last posted on 10/08/2022. First aid kit was observed to be complete. Facility did not have Staff files available for reviewed. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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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Document Has Been Signed on 01/10/2024 12:53 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: M&E CARE	FACILITY NUMBER: 079201021
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2024

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 observation, interview and record review, the licensee did not comply with the section cited above by not maintaining staff records at the facility. which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Administrator agreed to read and understand regulations and self certify and a copy of staff files to CCLD by the 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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: M&E CARE	FACILITY NUMBER: 079201021
	VISIT DATE: 01/10/2024

NARRATIVE

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Continued from LIC809.

LPAs observed the following deficiencies:

· At 11:40 am, LPAs observed Staff files not maintained at the facility.

LPAs requested the following documents to be submitted to CCLD by 01/24/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

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 this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC809 (FAS) - (06/04)

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