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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200734
Report Date: 10/04/2023
Date Signed: 10/04/2023 02:43:17 PM

Document Has Been Signed on 10/04/2023 02:43 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:BAY CARE ASSISTED LIVING LLCFACILITY NUMBER:
079200734
ADMINISTRATOR:ONYEAGOCHA, ROSE CFACILITY TYPE:
740
ADDRESS:2352 SHANNON AVETELEPHONE:
(510) 964-1669
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 4DATE:
10/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mary Burgess-Shaw, CaregiverTIME COMPLETED:
02:00 PM
NARRATIVE
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On 10/4/2023 at 10:15am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Mary Burgess-Shaw, Caregiver, and explained the purpose of the visit. Rose Onyeagocha, Administrator, arrived at 11:08am. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden residents.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and back yard. The facility consists of six (6) and three (3) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 72 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 116.4 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 10/20/2022. Emergency Disaster Plan was last posted on 10/10/2019.

LPA reviewed four (4) staff files and three (3) of four were incomplete. LPA reviewed all four (4) resident files and all were incomplete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734
VISIT DATE: 10/04/2023
NARRATIVE
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Continued from LIC809.

LPA observed the following deficiencies:
  • At 10:25am, LPA observed S2 was fingerprinted or associated to the facility.
  • At 10:35am, LPA observed facility does not have a 7-days of non-perishables and 2-days perishables available for residents.
  • At 10:40am, LPA observed during record review there is not a doctor's order for a hospital bed for R1.
  • At 10:50am, LPA observed a chest of drawers, 2 wheelchairs, a walker, a step ladder, and a bedframe in back yard..
  • At 11:15am, LPA observed during record review that resident records were incomplete.
  • At 11:30am, LPA observed during record review that staff records were incomplete.
  • At 11:30am, LPA observed during record review three (3) of the four (4) staff records does not contain a first aid certification.
  • At 11:30am, LPA observed during record review that staff does not have any training records.


LPA requested the following documents to be submitted to CCLD by 10/11/2023.
  • Resident Roster
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (9 pages)
  • Liability Insurance


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734
VISIT DATE: 10/04/2023
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.

*An immediate $500.00 civil penalty will be assessed on today's date for association.*

Exit interview conducted. A copy of the LIC421BG, this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 10/04/2023 02:43 PM - It Cannot Be Edited


Created By: Laura Hall On 10/04/2023 at 01:20 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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having staff first aid certified which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
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2
3
4
Administrator agreed to have all staff first aid certified and submit a copy of each staff certification to CCLD by POC date.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having any of the staff trained within first two weeks of employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
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2
3
4
Administrator agreed to have all staff trained and submit self-certification that the training have been completed 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: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


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Document Has Been Signed on 10/04/2023 02:43 PM - It Cannot Be Edited


Created By: Laura Hall On 10/04/2023 at 01:20 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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in the resident records completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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The administrator agreed to complete the resident records and submit self-certification that the records are completed to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(3)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having a doctor's order for the bedrails for R1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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Administrator agreed to obtain a doctor's order for the bedrails and submit a copy 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/04/2023 02:43 PM - It Cannot Be Edited


Created By: Laura Hall On 10/04/2023 at 01:24 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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(d)(3)
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having S2 fingerprinted and associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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Administrator agreed to have S2 fingerprinted and submit document 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: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


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Document Has Been Signed on 10/04/2023 02:43 PM - It Cannot Be Edited


Created By: Laura Hall On 10/04/2023 at 01:27 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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(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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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having the personnel records complete which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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2
3
4
Administrator agreed to have all staff records completed and submit self-certification to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises

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 7-day of non perishable and 2-day perishable foods for residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2023
Plan of Correction
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Administrator agreed to purchase food and submit pictures of food and reciepts 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: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


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Document Has Been Signed on 10/04/2023 02:43 PM - It Cannot Be Edited


Created By: Laura Hall On 10/04/2023 at 01:50 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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(6)
87705 Care of Persons with Dementia
(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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having a walker, 2 wheelchair, a chest of drawers and other items in back yard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2023
Plan of Correction
1
2
3
4
Administrator agreed to remove all items and submit a photo of back yard to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


LIC809 (FAS) - (06/04)
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