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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601541
Report Date: 05/05/2022
Date Signed: 05/05/2022 02:46:25 PM

Document Has Been Signed on 05/05/2022 02:46 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:WAGAYA ASSISTED LIVINGFACILITY NUMBER:
075601541
ADMINISTRATOR:KATSUMOTO, MINORUFACILITY TYPE:
740
ADDRESS:905 ELM STREETTELEPHONE:
5109657678
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 6CENSUS: 6DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Administrator, Minoru KatsumotoTIME COMPLETED:
03:00 PM
NARRATIVE
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On 05/05/2022 at 12:09 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection, LPA was greeted by one staff upon entry and explained the purpose of the visit. The Administrator, Minoru Katsumoto (ADM) was telephoned by the staff member and arrived about 15 minutes later.

Facility has a COVID-19 mitigation plan on file. LPA obtained a staff roster from ADM. LPA observed screening station at the entry that contained a thermometer, hand sanitizer, COVID-19 signage and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. LPA observed cough etiquette and hand washing signs posted. There was a sufficient supply of 7-day perishables and 2-day supply of non-perishable foods. All hand washing stations were equipped with soap and paper towels. Hot water temperature in the shared residents' bathroom was measured at 116.2 degrees Fahrenheit (F) and facility temperature was 73 degrees (F). Fire extinguisher was observed full. Smoke/Carbon Monoxide detectors were observed operational.

The following forms are to be updated and submitted to CCLD by 05/12/2022:
-Resident Roster
-LIC500 Personnel Report (Received)
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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
Document Has Been Signed on 05/05/2022 02:46 PM - It Cannot Be Edited


Created By: Lisha Holmes On 05/05/2022 at 01:38 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: WAGAYA ASSISTED LIVING
FACILITY NUMBER: 075601541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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 meet this requirement, as one (1) upper cabinet and (1) lower kitchen cabinet are missing from the hinges, which poses an immediate safety risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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ADM to provide photo to CCLD on or before 05/31/2022.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not meet this requirement, as the dishwasher had leaked in the kitchen and a basin and towel were on the floor to capture the water, which poses an immediate safety risk to persons in care.
POC Due Date: 05/05/2022
Plan of Correction
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ADM removed basin and towel prior to LPA leaving on 05/05/2022.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/05/2022 02:46 PM - It Cannot Be Edited


Created By: Lisha Holmes On 05/05/2022 at 01:38 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: WAGAYA ASSISTED LIVING
FACILITY NUMBER: 075601541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not meet this requirement, as the passageway to the backyard has obstructions that include a refrigerator, washing machine, dishes, foam packaging, rice cooker and tree debris which poses an immediate safety risk to persons in care.
POC Due Date: 05/26/2022
Plan of Correction
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ADM to provide photo to CCLD on or before 05/26/2022.
Type B
Section Cited
CCR
87555(b)(21)
General Food Service Requirements
(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not meet this requirement, as the refrigerator has food and liquid spillage inside and dust on the bottom vents, which poses an immediate safety risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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ADM to provide photo to CCLD on or before 05/09/2022.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/05/2022 02:46 PM - It Cannot Be Edited


Created By: Lisha Holmes On 05/05/2022 at 01:38 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: WAGAYA ASSISTED LIVING
FACILITY NUMBER: 075601541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not meet this requirement, as the stove arm is broken, and stove top vents, refrigerator vents, oven, and refrigerator are not clean, which poses an immediate safety risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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ADM to provide photo to CCLD on or before 05/12/2022.
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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
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