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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440265
Report Date: 03/01/2022
Date Signed: 03/01/2022 03:26:35 PM

Document Has Been Signed on 03/01/2022 03:26 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:WISDOM PATHFACILITY NUMBER:
011440265
ADMINISTRATOR:EASTMAN, SHIRLEYFACILITY TYPE:
775
ADDRESS:985 SUEIRROTELEPHONE:
(510) 783-1174
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 50CENSUS: 0DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Staff Stephanie Chones-HenriettaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with staff, Stephanie Chones-Henriettta. LPA spoke with Program Director Shirley Eastman over the phone. Shirley authorized Stephanie to be with LPA for inspection and to sign and receive this report. LPA also met with other staff, Jenalyn Oliveri and Alexandra Barry.

Facility has an approved LIC808 COVID-19 Mitigation Plan.

LPA inspected the facility with Stephanie. The program attendees/clients are gone for the day and LPA observed the staff cleaning and disinfecting the facility. LPA observed screening station by the front entrance with visitor's log, hand sanitizer, surgical masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and clients and recorded daily. Trash bins were observed with pedal operated lids. Centrally stored PPEs inspected and observed adequate. There were COVID-19 signages/posters all throughout the facility and hand washing signs on all bathroom/toilets.

Fire extinguishers inspected and tags showed serviced April 21, 2019 and observed fully charged.
When discussed, Shirley stated the extinguishers were inspected last year and scheduled to be inspected again sometime next month. The two-in-one smoke and carbon monoxide detectors were operational.

LPA tested the water temperature in one of the bathrooms and measured at 124 degrees Fahrenheit.

LPA verified and Shirley stated staff were not fit tested for N95 respirator.

.......continued next page (809C)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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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: WISDOM PATH
FACILITY NUMBER: 011440265
VISIT DATE: 03/01/2022
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The following updated documents need to be submitted by March 15, 2022:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed with Shirley over the phone in the presence of Stephanie.

Exit interview conducted. Appeal Rights, LIC9098 and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/01/2022 03:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/01/2022 at 03:03 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: WISDOM PATH
FACILITY NUMBER: 011440265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
82088 Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)

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. LPA tested the hot water temperature and was measured at 124 degrees Fahrenheit.
POC Due Date: 03/02/2022
Plan of Correction
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Program Director stated she'll have the water temperature adjusted by tomorrow, 3/02/2022.
In addition, an in-service to be conducted.
Proof to be submitted by 3/02/2022.
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
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