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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601541
Report Date: 03/24/2025
Date Signed: 04/01/2025 12:46:23 PM

Document Has Been Signed on 04/01/2025 12:46 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/
DIRECTOR:		KATSUMOTO, MINORUFACILITY TYPE:
740
ADDRESS:905 ELM STREETTELEPHONE:
(510) 965-7678
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 6CENSUS: 6DATE:
03/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Minoru Katsumoto, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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On 03/24/2024 around 01:15 PM, LPA arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Minoru Katsumoto, Administrator (ADM) and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of six (6) non-ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, storage, front yard and backyard. All outdoor and indoor passageways are kept free of obstruction. There were no bodies of water. A comfortable temperature for clients is maintained at 73 degree Fahrenheit. LPA observed lighting in all rooms to be adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 106.1. Toilets, hand washing and bathing areas were safe, sanitary and in operating condition. There were supplies of extra hygiene, paper products and emergency water available for staff and clients. There was a minimum one week supply of non-perishables and 2-day of perishables foods.

Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 07/09/24. First aid kit was observed to complete.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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 5
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: WAGAYA ASSISTED LIVING
FACILITY NUMBER: 075601541
VISIT DATE: 03/24/2025
NARRATIVE
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...continued from LIC809.

LPA reviewed 6 client records, and 3 staff records; all are incomplete.

-At 03:05 PM, LPA observed resident records incomplete.
-At 03:20 PM, LPA observed staff records incomplete.
-At 03:30 PM, LPA observed staff records missing required training.

-The following forms are to be updated and submitted to CCLD by 03/31/2025:
-Resident Roster (Reviewed)
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-Administrator Certificate (Reviewed) to be posted. 7005712740 exp: 08/09/26
-Emergency Disaster Drill

Deficiencies observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights, and a copy of this report provided to ADM.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/01/2025 12:46 PM - It Cannot Be Edited


Created By: Lisha Holmes On 03/24/2025 at 04:50 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: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)
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



This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and records reviewed, the licensee did not comply with the section cited above in 2 out of 3 staff not having annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
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2
3
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Administrator to review regulation, schedule training for staff, and provide proof with signatures to CCLD by the 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
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Based on observation, interview and records reviewed, the licensee did not comply with the section cited above in 2 out of 3 staff records being incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
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Administrator to review regulation, complete all staff records, and provide proof with signatures to CCLD by 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Lisha Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/01/2025 12:46 PM - It Cannot Be Edited


Created By: Lisha Holmes On 03/24/2025 at 05:04 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: 03/24/2025

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
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2
3
4
Based on observation, interview and records reviewed, the licensee did not comply with the section cited above in 6 out of 6 resident records being incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
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2
3
4
Administrator to review regulation, complete all resident records, and provide proof with signatures to CCLD by the POC date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Lisha Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


LIC809 (FAS) - (06/04)
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