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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200693
Report Date: 03/23/2023
Date Signed: 03/23/2023 07:26:48 PM

Document Has Been Signed on 03/23/2023 07:26 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:A-N-D CARE HOMESFACILITY NUMBER:
019200693
ADMINISTRATOR:HAMZA, MORENIKEFACILITY TYPE:
740
ADDRESS:3284 COURTHOUSE PLACETELEPHONE:
(510) 574-9305
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 3CENSUS: 3DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Morenke HamzaTIME COMPLETED:
05:15 PM
NARRATIVE
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On 3/23/2023 at 2pm, Licensing Program Analysts (LPAs) Luisa Fontanilla and Liridon Fici arrived unannounced to conduct required annual inspection and met with Morenike and Ade Hamza.

LPAs observed there was sufficient supply of perishable and non perishable foods. There was ample supply of blankets, towels, sheets and hygiene products available for use of residents. Facility has an approved fire clearance for 3 non ambulatory residents and 2 hospice. Carbon monoxide was tested and observed functional. Fire extinguisher appeared full and was last serviced on 8/17/22. First aid kit was observed complete.

At 2:15 pm, LPAs observed hot water temperature measured at 135 degrees Fahrenheit in the bathroom.

At 3:00 pm, LPAs reviewed medication, medication log, staff and resident records. LPAs observed Administrator and co Administrator have expired first aid and CPR training. Last First Aid/CPR training was done on 4/01/2018.

Deficiencies were cited per Title 22 California Code of Regulations. Failure to correct deficiencies by due date may result to civil penalty.

Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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 03/23/2023 07:26 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/23/2023 at 04:28 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: A-N-D CARE HOMES
FACILITY NUMBER: 019200693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows:

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


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. Hot water measured at 135 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2023
Plan of Correction
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Water temperature was adjusted to temperature within range during the visit. Deficiency cleared.
Type A
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in having both Administrator/Co Administrator First Aid and CPR expired. Last First Aid/CPR training was done on 4/1//2018
POC Due Date: 03/30/2023
Plan of Correction
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By POC date, Administrator will submit proof of current First Aid and CPR training.
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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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