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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601315
Report Date: 08/19/2024
Date Signed: 08/19/2024 02:19:37 PM

Document Has Been Signed on 08/19/2024 02:19 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ISHERWOOD CARE IIIFACILITY NUMBER:
015601315
ADMINISTRATOR/
DIRECTOR:		CAYABYAB, LAURO & ZORAIDAFACILITY TYPE:
740
ADDRESS:1445 SKELTON AVENUETELEPHONE:
(510) 894-4571
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 5DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Larry Cayabyab, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 08/19/2024 at 11:20 AM, Licensing Program Analysts (LPAs) P. Manalo and Jill Clancy-Czuleger arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Larry Cayabyab and explained the purpose of the visit. Administrator certificate is current (#700256740).

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 5 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 75 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 114.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 08/16/2023.

At 12:10 P.M, LPA reviewed 5 residents records. At 11:45 A.M, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.

The following deficiencies were observed:
Nail polish remover was found in common area.

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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 08/19/2024 02:19 PM - It Cannot Be Edited


Created By: Patricia Manalo On 08/19/2024 at 01:55 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: 08/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 by having nail polish remover left out and accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2024
Plan of Correction
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The administrator agrees to relocate the nail polish remover to a lock location and agrees to submit a written certification indicating the understanding of the regulation. Proof of correction will be sent to CCLD by POC date.
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:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


LIC809 (FAS) - (06/04)
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