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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201353
Report Date: 06/30/2025
Date Signed: 06/30/2025 02:50:03 PM

Document Has Been Signed on 06/30/2025 02:50 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:YVONNE'S HOME CARE SERVICESFACILITY NUMBER:
079201353
ADMINISTRATOR/
DIRECTOR:		DANIELS, CAROLYNFACILITY TYPE:
740
ADDRESS:2856 SHANE DRIVETELEPHONE:
(510) 964-4600
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 6DATE:
06/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:ANTHONY MERRIDA, CARE STAFFTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 06/30/25 at 10AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct an annual required inspection. LPA met with Care Staff Anthony Merida and explained the purpose of the visit. Administrator Carolyn Daniels arrived at 11:00AM. Administrator has current administrator certificate# 7034379740 which expires on 08/04/2025.

LPA toured the facility including but not limited to bedrooms, bathroom, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed and in working condition. Fire extinguishers were observed to be full and last serviced on 02/01/2024. One week of nonperishable and 2-day of perishable food supplies were available. LPA observed a non-skid mat in the bathroom. There were adequate lights in each room. First Aid kit is complete. No documentation on when the Last disaster drill was conducted.

LPA reviewed 3 clients and 3 staff files. Staff files were complete. Resident files were not complete complete. Staff were fingerprint cleared and associated to the facility. LPA reviewed a sample of client's medications during inspection. LPA measured hot water at 107.6 degrees F in the hallway bathroom.

CONTINUE ON LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2025
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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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: YVONNE'S HOME CARE SERVICES
FACILITY NUMBER: 079201353
VISIT DATE: 06/30/2025
NARRATIVE
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CONTINUE FROM LIC 809

Deficiencies observed during visit:
  • No emergency and disaster plan.
  • No documentation of a disaster drill conducted.
  • Expired fire extinguisher.
  • soiled carpet throughout the facility, spider webs and dust on the curtains in the bedrooms and on side of a dresser in room number 2, bedroom doors need to be repainted, closet door in bedroom 1 need to be replaced and cleaned. bathroom sink, bathtub, floors need to be clean and disinfected, door needs to be repainted. kitchen counter has a tile missing on the counter top, freezer in the garage leaking and needs to be cleaned, kitchen chairs need to be cleaned and sanitized, refrigerator inside and out needs to be cleaned and sanitized, oven needs to be replaced. Weeds in the front, back and side yards need to be cut and removed
  • incomplete resident records

Provide a copy of updated documents by 7/08/2025:

 LIC500- Personnel Report
 Resident Roster
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan including infection control plans
 Evidence of Liability Insurance

The deficiency was 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 with Carolyn Daniels. A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 06/30/2025 02:50 PM - It Cannot Be Edited


Created By: Carol Fowler On 06/30/2025 at 01:07 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: YVONNE'S HOME CARE SERVICES
FACILITY NUMBER: 079201353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 by not having an emergency and disaster plan which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/02/2025
Plan of Correction
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Administrator agreed to complete for and provide a copy to the department via email by the POC date.
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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2025 02:50 PM - It Cannot Be Edited


Created By: Carol Fowler On 06/30/2025 at 01:07 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: YVONNE'S HOME CARE SERVICES
FACILITY NUMBER: 079201353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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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Based on interview and record review, the licensee did not comply with the section cited above by not conducting or having documentation of drills which poses a potential health and safety risk to persons in care.
POC Due Date: 07/02/2025
Plan of Correction
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Administrator agreed to conduct an emergency disaster drill for each shift and provide a copy of the documentation with signatures to the department by the POC date.
Type B
Section Cited
CCR
87203

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, the licensee did not comply with the section cited above in by not having fire extinguishers updated with current fire tags which poses a potential health and safety risk to persons in care..
POC Due Date: 07/02/2025
Plan of Correction
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Administrator agreed to send a copy of receipt and photo of updated fire tags to department by POC due 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2025 02:50 PM - It Cannot Be Edited


Created By: Carol Fowler On 06/30/2025 at 01:28 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: YVONNE'S HOME CARE SERVICES
FACILITY NUMBER: 079201353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) 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 administrator did not comply with the section above by having soiled carpet throughout the facility, spider webs and dust on the curtains in the bedrooms and on side of a dresser in room number 2, bedroom doors need to be repainted, closet door in bedroom 1 need to be replaced and cleaned. bathroom sink, bathtub, floors need to be clean and disinfected, door needs to be repainted. kitchen counter has a tile missing on the countertop, freezer in the garage leaking and needs to be cleaned, kitchen chairs need to be cleaned and sanitized, refrigerator inside and out needs to be cleaned and sanitized, oven needs to be replaced. Weeds in the front, back and side yards need to be cut and removed.
POC Due Date: 07/18/2025
Plan of Correction
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Administrator agreed to have all items corrected and photos provided to the department by the POC date.
Type B
Section Cited
CCR
87506(b)
87506(b)
(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 record review, the administrator did not comply with the section cited above by having incomplete resident records which poses a potential health and safety risk to persons in care..
POC Due Date: 07/18/2025
Plan of Correction
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Administrator agrees to update and complete all resident records, self certify and send a sample of a complete file 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
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