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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601127
Report Date: 04/09/2025
Date Signed: 04/09/2025 04:52:15 PM

Document Has Been Signed on 04/09/2025 04:52 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: 5DATE:
04/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:ARTHUR PANELO, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On 4/9/2025 at 1:05 PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with staff Arthur Panelo, Administrator. LPA explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non ambulatory.

LPA toured facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathroom is equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods.

Smoke detectors and carbon monoxide detector were in operating condition during visit. LPA observed a purchased extinguisher with receipt attached dated 5/14/2024. First aid kit was observed to be complete.

LPA reviewed 4 residents records. LPA reviewed 3 staff records all 3 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications.

Report continues on 809 C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127
VISIT DATE: 04/09/2025
NARRATIVE
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continue from LIC 809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/24/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiencies were observed:

At- 1:27pm LPA observed medication (ketoconazole 2%) in R1's night stand drawer.

At- 1:31pm LPA observed a weekly pre-poured medication organizer with medications located in the locked medication cabinet.

At- 1:38pm LPA observed a lighter, scissors, medication loperamide Hydrochloride, Alaway eye drops and a screw driver. all located in the kitchen in a desk drawer.

At- 1:42pm LPA observed an unlocked garage with unlocked Tide, WD40, Wind Fresh laundry, Lysol, Pine Sol, and other chemicals a tool box with tools and lighters.

At- 1:46pm LPA observed a garbage can, fire extinguisher, commode, shower chair, mattress, foam mattress pad, Dolly, bed rail, all located in the side and back yard.

The following deficiencies were observed (see LIC 809 D) and cited from the California Code of Regulations, Title 22 and Failure to correct deficiencies by POC date may result in additional Civil Penalties.



Exit interview conducted. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 04/09/2025 04:52 PM - It Cannot Be Edited


Created By: Carol Fowler On 04/09/2025 at 03:42 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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(e)
(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. (e) Medications that are centrally stored shall be stored as specified in Section 87465, Incidental Medical and Dental Care Services.

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 by having unlocked medication located in a residents drawer and having unlocked chemicals such as Tide, WD-40, Wind Fresh laundry detergent, Lysol, Pine Sol, lighters, toolbox, located in the garage which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
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Administrator agreed to keep residents medication and the cabinet with the chemicals locked at all times. DEFICIENCY CLEARED DURING VISIT.
Type A
Section Cited
CCR
87465(h)(5)
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 by having pre-poured medication which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Administrator will submit a written statement of having read and understood the regulation and conducted in-service training with all staff, providing CCLD with a copy of all signatures of staff attended no later than the POC date.
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:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/09/2025 04:52 PM - It Cannot Be Edited


Created By: Carol Fowler On 04/09/2025 at 04:11 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: MAYON BOARD AND CARE, INC.
FACILITY NUMBER: 075601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025

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
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Based on Observation, the licensee did not comply with the section cited above by having a fire extinguisher, commode, shower chair, mattress, foam mattress pad, walker, dolly, bed rail all located on the side and back yard which poses a potential health and safety risk to residents in care.
POC Due Date: 04/22/2025
Plan of Correction
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Administrator agreed to remove ire extinguisher, commode, shower chair, mattress, foam mattress pad, walker, dolly, bed rail and provide photos to the Department by the POC date.
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:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
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