<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803996
Report Date: 11/28/2023
Date Signed: 11/28/2023 12:32:32 PM

Document Has Been Signed on 11/28/2023 12:32 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AGING IN THE BAY 2FACILITY NUMBER:
486803996
ADMINISTRATOR:MENDAROS, CHARMAINEFACILITY TYPE:
740
ADDRESS:1325 POTRERO CIRCLETELEPHONE:
(510) 388-7352
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 4DATE:
11/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Back-up Administrator/Caregiver, Mary Ann Ordono
Licensee, Charmaine Mendaros		TIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Aging in the Bay 2 for the purpose of conducting a Case Management-Annual Continuation. LPA was greeted at the door by Back-up Administrator/Caregiver, Mary Ann Ordono and was granted access into the facility. Administrator, Charmaine Mendaros arrived 1 hour later. Upon checking background clearances, LPA observed that Back-up Administrator/Caregiver, Mary Ann Ordono was not associated to the facility (See LIC 9102-Technical Violation). LPA educated the Administrator regarding associating new employees.

During this Case Management-Annual Continuation, LPA reviewed resident and staff records. Resident and staff interviews were conducted. Medication Orders were reviewed. LPA observed during the review that a resident had the label of the medication ripped off (See LIC 812-Observation). LPA educated the Administrator regarding labels on medications should be clearly read and identifiable to the medication, dosages and prescribing physician (See LIC 809D). During record review, LPA observed that 2 out of 4 residents did not have Reappraisals conducted yearly as outlined in Title 22 regulations (See LIC 809D). LPA educated the Administrator regarding the importance of conducting reappraisals annually as outlined in Title 22 regulations. LPA requested the following documents to be sent: LIC 500-Personnel Report, LIC 308-Designation of Responsibility, Liability insurance, Control of Property, Client Roster and Staff Roster

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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 3
Document Has Been Signed on 11/28/2023 12:32 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 11/28/2023 at 11:05 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AGING IN THE BAY 2
FACILITY NUMBER: 486803996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

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 2 out of 4 residents did not have Reappraisals conducted yearly as outlined in Title 22 regulations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
1
2
3
4
Plan of Correction shall include submitting an LIC 9098 understanding of this regulation. In addition, Administrator shall conduct reappraisals on ALL residents and retain those reappraisals in files. Administrator shall submit a plan for future compliance.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, a resident had the label of the medication ripped off which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
1
2
3
4
Plan of Correction shall include submitting an LIC 9098 understanding of this regulation. In addition, Administrator shall obtain an updated Medication bottle that reflects the proper documentation. Administrator shall submit a plan for future compliance.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3