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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201270
Report Date: 10/29/2024
Date Signed: 10/29/2024 01:27:27 PM

Document Has Been Signed on 10/29/2024 01:27 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:TOYON CARE IIFACILITY NUMBER:
079201270
ADMINISTRATOR/
DIRECTOR:		WEI, ANGELAFACILITY TYPE:
740
ADDRESS:2365 WRIGHT AVETELEPHONE:
(510) 408-6536
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 6CENSUS: 2DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:ANGELA WEI, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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On 10/29//2024 at 10:30 AM, Licensing Program Analyst (LPA) Carol Fowler, conducted an unannounced annual 1-year required inspection. LPA met with Angela Wei, Administrator. The facility’s fire clearance was approved for six (6) non-ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) bedrooms and three (3) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared clients’ bathroom was measured at 114.3 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. The emergency disaster plan was last updated 10/03/2023. Fire extinguisher was purchased on 09/11/2024. Fire drill last conducted 09/20/2024. First aid kit was observed to be complete.

continue on LIC 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
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: TOYON CARE II
FACILITY NUMBER: 079201270
VISIT DATE: 10/29/2024
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Continue from LIC 809

LPA reviewed two (2) residents files which were all complete. LPA reviewed three (3) staff files which were all complete.

LPA observed the following deficiencies:
· At 10:58 AM, LPA observed both side gates locked from the outside with a metal wire.
· At 11:01 AM, LPA observed Administrators unlocked medications sitting on top of a desk.
· At 11:02 AM, LPA observed unlocked scissors in a container, chemicals located under the sink unlocked located in the kitchen.
  • At 11:05 AM, LPA observed 4 lighters and matches in an unlocked drawer in the kitchen.
  • At 11:08 AM, LPA observed pre-poured medication unlocked in a cabinet in the kitchen.
  • At 11:19 AM, LPA observed sharps cabinet with a lock but had an opening at the top which made sharps accessible to residents.


LPAs requested the following documents to be submitted to CCLD by 11/12/2024
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • Liability Insurance

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

Exit interview conducted and a copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
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 01:27 PM - It Cannot Be Edited


Created By: Carol Fowler On 10/29/2024 at 12:30 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: TOYON CARE II
FACILITY NUMBER: 079201270

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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.

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 chemicals unlocked stored in the kitchen cabinet, the bathroom cabinet, scissors, 4 lighters, matches, all unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Administrator removed all items and locked them away. DEFICIENCY CLEARED DURING VISIT
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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 by having Administrator medications Nivesco Inhalation Aerosol, Body Heat tablets and Visine unlocked sitting a desk and residents pre-poured medication unlocked in a kitchen cabinet and Neosporin in an unlocked cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Administrator locked all medications. and will read and understand regulation and self certify and submit a copy of the certification to the Department 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
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 01:27 PM - It Cannot Be Edited


Created By: Carol Fowler On 10/29/2024 at 01:04 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: TOYON CARE II
FACILITY NUMBER: 079201270

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(I)(2)
87705 Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

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 being unable to open both backyard gates because they were locked with a metal wire from the outside which poses an immediate health & safety risk for persons in care.
POC Due Date: 11/26/2024
Plan of Correction
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Administrator agreed to remove the lock on the gate and to submit a picture to CCLD by POC due date.
Administrator will complete an In-Service training with Staff and will send a copy with each Staff's signature.

Facility is being assess $500 civil penalty for todays visit.
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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
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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