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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201119
Report Date: 04/08/2025
Date Signed: 04/08/2025 05:01:36 PM

Document Has Been Signed on 04/08/2025 05:01 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:
04/08/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Virginia Rulete and
Blesilda Yamat, Staff		TIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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 On this day, 4/08/25, at 11:45 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on 3/28/25. LPA met with staff, Larry Poblete, Evangelien Porter and Gerald Cayle Garcia, and informed the reason for visit. LPA called and spoke over the phone with Leticia Velasco, licensee, who arrived at around 12:25 pm. Max Neri, administrator (ADM) arrived at around 1:00 pm.

Disaster drill record on file was dated 1/10/25. There's no record as proof drills were conducted on previous quarters.

LPA reviewed 5 staff and 5 residents' files. Residents medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.

LPA observed the following:
-at 12:20 pm, staff (S2) does have LIC501 Personnel Record, LIC503 Health Screening, TB test and 40 hours required training on file.
-at 12:35 pm, staff (S4) is not associated to this facility. Does not have LIC503 Health Screening, TB test, required 40 hours training and first aid certificate on file.
-at 12:40 pm, staff (S5) does not have LIC503 Health Screening, TB test, required 40 hours training and first aid certificate on file.

.......continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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 11
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)
Page: 2 of 11
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: 04/08/2025
NARRATIVE
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-at 1:05 pm, resident's (R1) LIC602A indicated ambulatory but resident has major neurocognitive disorder. LIC625 on file is over a year old.
-at 1:17 pm, resident's (R2) LIC602A on file dated 2023 indicated bedridden but R2 was observed able to ambulate using walker. LIC602A indicated major neurocognitive disorder. LIC625 is over a year old.
-at 1:25 pm, resident's (R3) LIC625 Appraisal/Needs Services Plan not properly filled-up - incomplete; page 2 blank; page 3 no care plan. No doctor's order on file for half bed rails.
-at 1:40 pm, resident's (R4) LIC602A is over a year old; does not have Pre-Admission Appraisal and LIC625 Appraisal/Needs and Services Plan. Half bed rails does not have doctor's order on file.
-at 2:10 pm, resident's (R5) 2 medications received by the facility not properly recorded on LIC622.

Administrator to submit current/updated copies of the following documents by April 22, 2025:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages).
4. $3M Liability Insurance certificate

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

Deficiencies and plan and proof of corrections were discussed with ADM.

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: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 04/08/2025 05:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/08/2025 at 03:08 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: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
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) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
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Based on record review, the licensee did not comply with the section cited above in S4 not associated which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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2
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4
Administrator provided a copy of LIC9182 transfer request while LPA is at the facility.
In addition, administrator to submit the documents via email to the Oakland Regional Office by POC date.
Type B
Section Cited
CCR
87412(a)
87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in S2 does not having LIC501 Personnel Record on file which poses a potential safety and/or personal rights risks to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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Administrator to have the LIC501 completed and submit proof by 4/22/25.
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: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 04/08/2025 05:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/08/2025 at 03:29 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: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in R4 not having Pre-Admission Appraisal which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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Administrator to complete the Pre-Admission Appraisal and submit copy by 4/22/25.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R4 not having LIC625 Appraisal/Needs and Services Plan which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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Administrator to complete the LIC625 and submit copy by 4/22/25.
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: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 04/08/2025 05:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/08/2025 at 03:29 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: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(5)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, , the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: R1's LIC602A indicated ambulatory but resident has major neurocognitive disorder. R2's LIC602A indicated bedridden but R2 was observed able to ambulate using walker.
POC Due Date: 04/22/2025
Plan of Correction
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2
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Administator to have the LIC602As corrected and submit proof by 4/22/25.
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: R1 and R2's LIC625 over a year old; R3's LIC625 not properly filled-up.
POC Due Date: 04/22/2025
Plan of Correction
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2
3
4
Administrator to do re-appraisal and properly fill-up the LIC625. Self-certification to be submitted by 4/22/25.
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: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 04/08/2025 05:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/08/2025 at 03:29 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: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in not having records showing drills were conducted on previous quarters which pose a potential safety and/or personal rights risks to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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Administrator to read the Regulations and submit self-certification ensuring drills are conducted at least quarterly.
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General
(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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in S4 and S5 not having first aid certificate on file which pose a potential safety and/or personal rights risks to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
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2
3
4
Administrator to have the staff reqistered for training and submit copies of certificates by 4/22/25.
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: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 04/08/2025 05:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/08/2025 at 04:10 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: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
(11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in S2, S4 and S5 not having LIC503 on file which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
1
2
3
4
Administrator to have the staff health screened and submit proof by 4/22/25.
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician……

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in S2, S4 and S5 not having TB test on file which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
1
2
3
4
Administrator to have the staff TB tested and submit copies of test results by 4/22/25.
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: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 04/08/2025 05:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/08/2025 at 04:20 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: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1569.625(b)(1)
§1569.625 Staff training; legislative findings; contents: (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment.......................This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in S2, S4 and S5 not having the 40 hours required training on file which pose a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
1
2
3
4
Administrator to have the staff complete the training and submit proof by 4/22/25.

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: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 04/08/2025 05:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/08/2025 at 04:29 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: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in R5’s 2 medications received by the facility not properly recorded on LIC622 which posed a potential personal rights risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
1
2
3
4
Administrator to correct the LIC622 and submit proof by 4/22/25.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/08/2025 05:01 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/08/2025 at 04:47 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: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in R3 and R4’s half bed rails not having doctor's order on file which pose a potential safety and/or personal rights risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
1
2
3
4
Administrator to obtain doctor's order and submit copies by 4/22/25.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
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