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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201119
Report Date: 03/28/2025
Date Signed: 03/28/2025 07:01:50 PM

Document Has Been Signed on 03/28/2025 07:01 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/
DIRECTOR:		NERI, MAXFACILITY TYPE:
740
ADDRESS:23652 NEVADA ROADTELEPHONE:
(510) 821-0871
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
03/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:10 PM
MET WITH:Virginia Rulete and
Blesilda Yamat, Staff		TIME VISIT/
INSPECTION COMPLETED:
07:05 PM
NARRATIVE
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On this day, March 28, 2024, at 4:10 pm., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Virginia Rulete and Blesilda Yamat, and informed the reason for visit. LPA called and spoke over the phone with Leticia Velasco, licensee, and Max 'Mike' Neri, administrator (ADM). The licensee authorized to have the staff to be with LPA in touring the facility.

LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables.

Facility has smoke and carbon monoxide detectors that were observed in operating condition. Hot water temperature in the common bathroom was tested. Fire extinguisher was observed fully charge with tag showed serviced 3/06/25.

LPA observed the following:
-at 4:25 pm, medications in the refrigerator in unlocked garage.
-at 4:27 pm, unlocked kitchen shears and medication (Aspirin) in the kitchen cabinet.
-at 4:28 pm, kitchen cabinets where sharps and cleaning supplies are kept do not have an appropriate lock.
-at 4:30 pm, Vitamins and perineal skin protector in cabinet without lock in the area adjacent to the dining area.

...continued on 809C (page 2)
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 03/28/2025
NARRATIVE
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Page 2

-at 4:42 pm, shaving cream in one of the residents' rooms.
-at 4:43 pm, razor in food tray in another resident's room.
-at 4:44 pm, disinfectant and sanitizing sprays in the common bathroom.
-at 4:50 pm, hot water in the common bathroom was at 134.1 degrees Fahrenheit.
-at 5:02 pm, Isopropyl alcohol and urinary tract infection (UTI) pain reliever in the drawer in another residents' room.
-at 5:04 pm, piece of metal, mattress, bed frame and bed rail in the backyard.
-at 5:05 pm, rake outside the storage in the backyard.
-staff (S1) is fingerprint cleared, however, not associated to this facility.

Administrator to submit copies of the following updated/current documents by April 11, 2025:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)

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 additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with licensee and ADM over the phone. Licensee authorized Virginia Rulete to sign and receive this report.

Due to time constraint, LPA to come back to continue the inspection.

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

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/28/2025 07:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/28/2025 at 06:22 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: 03/28/2025

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 degrees C) and not more than 120 degree F (49 degrees 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 in hot water at 134.1 degrees Fahrenheit which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 03/29/2025
Plan of Correction
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Administrator to have the temperature adjusted within Regulations range and submit proof by 3/29/25.
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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/28/2025 07:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/28/2025 at 06:22 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: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 in the following which pose an immediate health, safety and/or personal rights risks to persons in care: medications in unlocked garage; unlocked kitchen shears and medication (Aspirin) in the kitchen cabinet; kitchen cabinets where sharps and cleaning supplies are kept do not have an appropriate lock; unlocked Vitamins and perineal skin protector; shaving cream, Isopropyl alcohol, UTI pain reliever and razor in residents' rooms; disinfectant and sanitizing sprays in the common bathroom
POC Due Date: 03/29/2025
Plan of Correction
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Staff put the items in the garage then locked the garage.
In additon, administrator to do the following and submit proof by 3/29/25:
1. Install lock in the cabinets.
2. In-service the staff and submit copy of training topic with attendees signatures.
Type A
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

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 in a rake outside the storage in the backyard which poses an immediate safety and/or personal rights risks to persons in care.
POC Due Date: 03/29/2025
Plan of Correction
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Staff temporarily locked the rake in the garage.
Administrator to do the following and submit proof by 3/29/25:
1. Put the rake in the storage.
2 In-service the staff and submit copy of training topic with attendees signatures.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/28/2025 07:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/28/2025 at 06:22 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: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 in rotten broccoli which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 03/29/2025
Plan of Correction
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Staff discarded the item.
Administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/29/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/28/2025 07:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/28/2025 at 06:22 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: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the following pose a potential safety and/or personal rights risks to persons in care: piece of metal, mattress, bed frame and bed rail in the backyard.
POC Due Date: 04/11/2025
Plan of Correction
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2
3
4
Administrator to have the yard cleaned and submit pictures by 4/11/25.
Type B
Section Cited
CCR
87355(e)(3)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(3) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on interview and review of facility roster in Guardian, the licensee did not comply with the section cited above in S1 not associated which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
1
2
3
4
Administrator to have the staff associated and submit proof by 4/11/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
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