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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201533
Report Date: 08/21/2025
Date Signed: 08/21/2025 02:41:07 PM

Document Has Been Signed on 08/21/2025 02:41 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:QUINCY WAY SENIOR LIVING LLCFACILITY NUMBER:
019201533
ADMINISTRATOR/
DIRECTOR:		HADI, HAIDARFACILITY TYPE:
740
ADDRESS:617 QUINCY WAYTELEPHONE:
(650) 270-8596
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 4CENSUS: 0DATE:
08/21/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Haidar Hadi/ApplicantTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On this day, August 21, 2025, at 11:00 am, Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing inspection. License application is for four (4) total capacity, all non-ambulatory. Fire clearance was granted on June 2, 2025. LPA met with Haidar Hadi, applicant. Application is an initial/new application for license for this location.

LPA toured the facility inside out. There is no body of water. LPA inspected the living room, dining area, kitchen, bedrooms, bathrooms, front, side and backyard. Central storage for medications was observed in the garage.

Fire extinguisher was observed fully charge and when verified, applicant stated it was purchased this year. LPA discussed for it to be serviced every year. Carbon monoxide and smoke detectors were tested and observed in operating condition. First aid kit was checked and observed complete with manual

LPA observed the following:
-the home has renter. LPA verified, and according to applicant all the furniture, kitchen utensils, cook ware, plates and microwave are owned by the renter.
-at 11:10 am, cracked kitchen counter, rusted sink.
-at 11:16 am, bed in the living room.
-at 11:20 am, mildew in the shower of the common bathroom, no grab bar in the shower, dirty toilet/shower, rusted towel paper holder, trash can without lid.

....continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2025
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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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: QUINCY WAY SENIOR LIVING LLC
FACILITY NUMBER: 019201533
VISIT DATE: 08/21/2025
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-at 11:30 am, ensuite bathroom dirty and with mildew, no grabs and non-slid mat, trash can without lid.
-at 11:32 am, rake, pieces of wood and metal, pieces of car doors, pails of paint, paint brush and pan, block of cement, tiles, weed killer, old chair and table in the side yard.
-at 11:36 am, uneven cemented area and with crack, broken mirror, pieces of wood and glass, bricks, pile of decorative cement blocks, worn out mattress and chair and headboard in the backyard.
-Complaint and Ombudsman posters, Residents Personal Rights, Rights to Resident Council, Rights to Family Council, Theft and Loss Policy not posted.
-facility sketch not consistent with the sketch submitted to Centralized Applications Bureau - orientation not correct, doors of the 2 bedrooms and closets in these bedrooms incorrectly labeled/indicated in the sketch.
-no call buttons for residents' use.
-fire extinguisher still in the box.
-no linens, paper towels and toilet paper, towel, wash cloths, hygiene supplies and non-perishable food supplies available.
-scratched, dusty flooring.
-no flashlights available; no telephone and internet service; no patio furniture in the yard.

Applicant stated he'll submit the proof of corrections (POCs) by October 21, 2025 for the following:
1. Have the renter move out.
2. Replace the kitchen counter and sink.
3. Install grab bars in the toiler and shower; clean the bathrooms; purchase trash cans with foot operated pedal lids.
4. Have the cement in the backyard leveled and repair the crack.
5. Clean the yard.
6. Replaced the flooring with industrial grade vinyl tiles.
7. Purchase the following: living room furniture; bedroom furniture including beds, bed frames, night stands and drawers; washer; microwave; kitchen utensils; silver wares; pots and pans; plates; flashlights; call buttons for residents' use; patio furniture
8. Mount the fire extinguisher.
9. Install lock in the closet by the dining area to be use as central storage for medications.

....continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: QUINCY WAY SENIOR LIVING LLC
FACILITY NUMBER: 019201533
VISIT DATE: 08/21/2025
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10. Post the following in the prominent place in the facility: Complaint and Ombudsman posters, Residents Personal Rights, Rights to Resident Council, Rights to Family Council, Theft and Loss Policy.
11. Call the telephone and internet service provider(s) for job order.

Applicant stated he wants to convert the staff bedroom to residents' room and increase the capacity from 4 to 5. The following to be submitted by October 21, 2025:
1. LIC200 for 5 total capacity.
3. Corrected/updated sketches showing the following:
-Exit doors and windows
-Dimensions and use of each room
-Number of resident(s) in each bedroom
-Utility shut off locations
-correct locations of closets and doors
-Outside sketch showing the building, perimeter fence, driveway and utility shut off locations.

Upon receipt of LIC200 and updated sketches, LPA to submit to Centralized Applications Bureau analyst who in turn will submit a new request for fire safety inspection.

LPA to do re-inspection once the new fire clearance is granted and corrections to the deficiencies are completed.

LPA discussed obtaining $3M liability insurance upon admission of first resident and to submit copy of the insurance certificate to LPA.

Exit interview conducted and copy of this report provided to applicant.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
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