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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400147
Report Date: 06/21/2022
Date Signed: 06/21/2022 03:04:21 PM

Document Has Been Signed on 06/21/2022 03:04 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:CREATIVE GROWTHFACILITY NUMBER:
011400147
ADMINISTRATOR:DIMARIA, TOMEFACILITY TYPE:
775
ADDRESS:355 - 24TH STREETTELEPHONE:
(510) 836-2340
CITY:OAKLANDSTATE: CAZIP CODE:
94612
CAPACITY: 90CENSUS: 27DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Amelia Berumen, Client Services ManagerTIME COMPLETED:
03:15 PM
NARRATIVE
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On 6/21/2022 starting at 12:45 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Client Services Manager, Amelia Berumen and disclosed the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, common areas, and kitchen. There is one central entry point for universal screening for staff and participants. Facility has sufficient PPE supply. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for staff and participants.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· Approximately at 1:05 p.m., a bottle of Advil and a bottle of Tylenol were observed in the unlocked cabinet located in the common area. Client Services Manager removed 2 bottles of medication to the office and locked them up during visit.
· Approximately at 1:15 p.m., unlocked knives and cleaning solutions were observed in the kitchen. Client Services Manager moved all knives to a locked cabinet under the sink and locked them up during inspection.

The above 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 with Client Services Manager. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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Document Has Been Signed on 06/21/2022 03:04 PM - It Cannot Be Edited


Created By: Catherine Lin On 06/21/2022 at 02:32 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: CREATIVE GROWTH
FACILITY NUMBER: 011400147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
82087 (a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, 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 and interview, the licensee did not comply with the section cited above. 2 knives were left on the table and kitchen counter top, more than 10 knives were in the unlocked kitchen drawer where accessible to participants, and also unlocked medications in the cabinet located in the common area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2022
Plan of Correction
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Client Services Manager moved all knives to another cabinet under the kitchen sink, and moved over-the-counter medications to the office, and locked then up during visit.
Client Services Manager agreed to retrain staff on related regulation and submit proof of training with staff signatures to CCL by the POC due 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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


LIC809 (FAS) - (06/04)
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