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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601127
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:56:26 PM

Document Has Been Signed on 10/29/2024 12:56 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:MAYON BOARD AND CARE, INC.FACILITY NUMBER:
075601127
ADMINISTRATOR/
DIRECTOR:		PANELO, ARTHUR H.FACILITY TYPE:
740
ADDRESS:1804 CONCORD COURTTELEPHONE:
(925) 825-5593
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Arthur Panelo, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 10/29/2024 LPA K. Nguyen conducted an unannounced case management visit, meeting with Licensee/Administrator Arthur Panelo regrading R1 death report. LPA interviewed administrator and W1. According to the administrator around 9am on 9/27/24 noticed R1 was making a weird sound when breathing. R1 have an appointment to see R1 doctor around 3pm accompany by R1 daughter. Around 1:27pm a visitor walked pass R1 room and noticed that R1 was having white fluid coming out from R1 nose. The family refused to put R1 on hospice, due to R1 culture. Around 1pm W1 called me over because W1 notice that there’s a fluid coming out from R1 nose. I checked on R1 and called 911 right away. I called R1 daughter and informed her of the situation. Administrator spoke with R1 daughter on 10/11/24 to confirmed R1 cause of death. R1 daughter confirmed that cause of death is cause of natural death, due to R1 is 102-year-old. Police where here and spoke with the family there was no concerned or questioned regrading R1 death.

No citation issue on this day.

An exit interview is conducted, and a copy of this report is provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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