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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201119
Report Date: 02/20/2023
Date Signed: 02/20/2023 04:50:10 PM

Document Has Been Signed on 02/20/2023 04:50 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:ABOVE & BEYOND RCFE, INC.FACILITY NUMBER:
019201119
ADMINISTRATOR:BOOKER, JOSEFINA VFACILITY TYPE:
740
ADDRESS:23652 NEVADA ROADTELEPHONE:
(510) 821-0871
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
02/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Josefina 'Josie' Booker/Administrator
and Leticia 'Lettie' Velasco		TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Gerald Garcia and Marlyn Joaquin, and informed the purpose of visit. Josefina 'Josie' Booker, administrator, arrived after about 16 minutes followed by Leticia 'Lettie' Velasco, licensee/

Facility has LIC9282 Infection Control Plan and approved LIC808 Mitigation Plan.

LPA started inspection with Gerald Garcia, and continued with Josefina Booker. LPA inspected the living room, dining area. family room, kitchen, hallways, residents bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe. Facility has Visitor's log. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked. Facility has antigen test kits readily available. COVID-19 signages were observed throughout the facility. Bathroom lavatories were observed with liquid soap.

Fire extinguisher checked, and observed fully charge with tag showed serviced July 28, 2022. Hot water temperature in the common bathroom was tested.

LPA observed the following:
1. Hot water temperature at 134 degrees Fahrenheit.
2. Medications in all 4 residents rooms.

.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2023
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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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: ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER: 019201119
VISIT DATE: 02/20/2023
NARRATIVE
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3. Cleaning supplies in unlocked garage and garage cabinets.
4. Door bell not working.
5. Rusted rake, bed frames, used bed, chicken wire. pieces of wood in the backyard.
6. Disposable face shields and gowns, and N95 respirators not sufficient for 30 days for 7 staff.

License and/or administrator to submit the following by March 6, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. Proof of $3M liability insurance.
5. Current N95 fit testing records/certificates

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with licensee and administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/20/2023 04:50 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/20/2023 at 04:09 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: ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER: 019201119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)(C)
87465 Incidental Medical and Dental Care
(h)(1)(C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others

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 medications in 4 out of 4 residents bedrooms and medication cabinet unlocked which poses an immediate safety risk to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
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Staff locked the medications and medication cabinet while LPA is at the facility.
In addition, licensee and/or administrator to in-service the staff and submit training topic with attendees signatures by 2/21/23.
Type A
Section Cited
CCR
87309(a)
87309 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.

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 rusted rake in the backyard and cleaning supplies in unlocked garage and garage cabinets which pose immediate safety risks to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
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Staff locked the rake and medication cabinet, and locked all the cleaning supplies cabinets in the garage.
In addition, licesnee and/or administrator to in-service the staff, and submit training topic with attendees’ signatures by 2/21/23.
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
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/20/2023 04:50 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/20/2023 at 04:14 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: ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER: 019201119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation
(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 for hot water at 134 degrees Fahrenheit which poses an immediate safety risk to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
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Staff adjusted the temperature to 105 degrees while LPA was still at the facility.
In addition, licensee and/or administrator to have the temperature regularly checked to ensure temperature is within Regulations range. Proof to be submitted by 2/21/23.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 02/20/2023 04:50 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/20/2023 at 04:17 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: ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER: 019201119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2023

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 the following in the backyard: bed frames, used bed, chicken wire. pieces of wood. LPA also observed the doorbell not working.
POC Due Date: 03/06/2023
Plan of Correction
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Staff locked the items in the storage and fixed the doorbell.
In addition, license and/or administrator to in-service the staff and submit training topic with attendees’ signatures by 3/06/23.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2023


LIC809 (FAS) - (06/04)
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