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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440265
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:57:02 PM

Document Has Been Signed on 11/03/2023 02:57 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: 18DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Shirley Eastman/Program DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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At 10:25 am on this day, November 3, 2023, Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual required inspection. LPA met with Program Director Shirley Eastman, and informed the purpose of visit.

Facility has an approved LIC808 Mitigation Plan but has not submitted the LIC9283 Infection Control Plan.

LPA toured the facility inside out with Shirley Eastman. LPA inspected the activity rooms, living room area, kitchen, quiet room, office, meeting room, side and backyard. Facility has adequate supplies of snacks and activity materials. Hallways were observed clear of hazards and obstruction. There were tables and chairs with shades in the backyard. Storage for cleaning supplies was observed locked.

Hot water temperature in one of the bathrooms was tested, and measured at 111.9 degrees Fahrenheit. Facility conducts disaster drills at least once every 3 months, and records showed last conducted October 31, 2023. Facility has 2 in one smoke and carbon monoxide detector that was tested and observed in operating condition.

LPA reviewed 5 staff and 5 residents files, and interviewed 2 staff and 3 clients.

LPA observed the following:
-at 12:03 pm, staff (S3) has no TB test and LIC503 Health Screening records on file.
-at 12:18 pm. staff (S5) has no LIC503 Health Screening record on file.
-at 1:25 to 1:40 pm. clients (C1 and C3) have no medical assessment. Clients (C1, C2, C3, C4 and C5) have no admission agreements of file

......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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: 11/03/2023
NARRATIVE
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LPA received the following updated documents on this day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report

Program Director to submit copies of following updated documents by November 17. 2023:
1. LIC610D Emergency Disaster Plan (9 pages)
2. LIC9283 Infection Control Plan

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Shirley Eastman.

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

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/03/2023 02:57 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/03/2023 at 01:58 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: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening, as specified in Section 82065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 (S3 and S5) of 5 staff not having LIC503 Health Screening records on file which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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2
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Program Director to have the staff health screened and submit copies of LIC503s by 11/17/234.
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on records review, licensee did not comply with the section cited above in 5 out of 5 clients not having admission agreements on file which pose a potential personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Program Director to have the admission agreements completed and send self-certification by 11/17/23,
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: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/03/2023 02:57 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/03/2023 at 01:58 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: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(f)(1)(B)
Needs and Services Plan
(f) The completed Needs and Services Plan shall include: (1) The client's desires and background and formal supports, obtained from the client's family or his/her authorized representative, if any, regarding the following: (B) A written medical assessment including primary physician, health problems and medical history, prescribed medications and their strength, quantity, frequency required and purpose as specified in Section 82069(b)(3).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 (C1 and C3) out of 5 clients not having medical assessments on file which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Program Director to obtain copies or LIC602/LIC602A, and submit self-certification indicating documents were obtained by 11/17/23.
Type B
Section Cited
CCR
82066(a)(11)
82066 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information:
(11) Tuberculosis test results, as specified in Section 82065(g)(1).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for S3 not having TB test on file which poses a potential health and/or personal rights risk to perspms in care.
POC Due Date: 11/18/2023
Plan of Correction
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Program Director to have the staff TB tested and submit proof by 11/17/23.
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: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
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