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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200392
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:01:32 PM

Document Has Been Signed on 10/29/2024 02:01 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:EMA BOARD AND CAREHOMEFACILITY NUMBER:
079200392
ADMINISTRATOR/
DIRECTOR:		EDWIN LIWANAGFACILITY TYPE:
740
ADDRESS:1131 ALAMO WAYTELEPHONE:
(925) 458-7098
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 10CENSUS: 5DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Merla Fernandez, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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On 10/29/2024 at 9:50am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Merla Fernandez, Caregiver, and explained the purpose of the visit. Administrator, Edwin Liwanag, arrived at 10:15am. The facility’s fire clearance was approved for eight (8) non-ambulatory and two (2) bedridden residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) bedrooms and three (3) bathrooms. One (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. No bodies of water observed. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 120.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/16/2022. Emergency Disaster Plan was last posted on 10/3/2023. First aid kit was observed to be complete. Fire drill was last conducted on 10/3/2023.

Continued on LIC809.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
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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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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392
VISIT DATE: 10/29/2024
NARRATIVE
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Continued from LIC809.

LPA reviewed four (4) staff and observed three (3) of four (4) files were current and complete. All five (5) resident files were reviewed current and complete. LPA reviewed a sample of medications.

LPA observed the following deficiencies:
  • At 10:10am, LPA observed during record review R1 did not have a hospice care plan.
  • At 10:30am, LPA observed during record review S4 personnel file was incomplete.
  • At 10:55am, LPA observed fire extinguisher was last serviced on 9/16/2022.
  • At 10:55am, LPA observed mice droppings in kitchen drawer and a large rat trap in garage.
  • At 10:55am, LPA observed milk of magnesia, mucinex, and Tussin in the refrigerator unlocked.
  • At 11:50am, LPA observed facility did not have working smoke detectors.
  • At 11:55am, LPA observed during record review facility has not conducted a fire drill.


LPA requested the following documents to be submitted to CCLD by 11/5/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (last page)
  • Liability Insurance


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
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
LIC809 (FAS) - (06/04)
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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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392
VISIT DATE: 10/29/2024
NARRATIVE
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Continued from LIC809C.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2024 02:01 PM - It Cannot Be Edited


Created By: Laura Hall On 10/29/2024 at 12:39 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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having S4 personnel file complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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2
3
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Administrator agreed to have S4 obtain a health screen including TB, complete a LIC501, and submit documents to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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 in keeping mice droppings out of kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Administrator agreed to submit two (2) current invoices for exterminator service or hire an exterminator and submit invoice to CCLD by 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


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Document Has Been Signed on 10/29/2024 02:01 PM - It Cannot Be Edited


Created By: Laura Hall On 10/29/2024 at 12:40 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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and record review, the licensee did not comply with the section cited above in having a hospice care plan for R1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Administrator agreed to obtain a hospice care plan for R1 and submit to CCLD by POC date.
Type B
Section Cited
CCR
87203
87203 Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having working smoke detectors and fire extinguisher serviced which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Administrator agreed to have fire extinguisher serviced and install smoke detectors and submit photos to CCLD by 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2024 02:01 PM - It Cannot Be Edited


Created By: Laura Hall On 10/29/2024 at 12:56 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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:

2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in having medications in refrigerator inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Administrator agreed to put medications that are in the refrigerator in a locked box and submit photo to CCLD by POC date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2024 02:01 PM - It Cannot Be Edited


Created By: Laura Hall On 10/29/2024 at 01:49 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: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in conducting a quarterly fire drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Administrator agreed to conduct a fire drill and submit form to CCLD by POC date.
Section Cited
Deficient Practice Statement
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4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


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