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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601315
Report Date: 08/23/2021
Date Signed: 08/23/2021 03:42:30 PM

Document Has Been Signed on 08/23/2021 03:42 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:ISHERWOOD CARE IIIFACILITY NUMBER:
015601315
ADMINISTRATOR:CAYABYAB, LAURO & ZORAIDAFACILITY TYPE:
740
ADDRESS:1445 SKELTON AVENUETELEPHONE:
(510) 894-4571
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 4DATE:
08/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Lauro CayabyabTIME COMPLETED:
03:45 PM
NARRATIVE
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On 8/23/2021 at 2:17pm, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Licensee Lauro Cyabyab and explained the purpose of the visit.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and backyard. All hand washing stations were equipped with soap, paper towels and garbage. LPA observed PPE, food and paper supplies are sufficient. Common areas are disinfected at least once a day. Carbon monoxide and smoke detectors were working.

During record review, it was confirmed that the facility has a mitigation plan on file.

LPA observed fire extinguisher was last serviced on February 26, 2018.

The following deficiency was observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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 08/23/2021 03:42 PM - It Cannot Be Edited


Created By: Allison O'Hollaren On 08/23/2021 at 03:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ISHERWOOD CARE III
FACILITY NUMBER: 015601315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed fire extinguisher was last serviced on February 26, 2018 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2021
Plan of Correction
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By POC date Licensee will have fire extinguisher serviced or replaced, and submit a copy of tag to CCL by fax or email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021


LIC809 (FAS) - (06/04)
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