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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440265
Report Date: 10/30/2024
Date Signed: 10/30/2024 02:45:06 PM

Document Has Been Signed on 10/30/2024 02:45 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/
DIRECTOR:		EASTMAN, SHIRLEYFACILITY TYPE:
775
ADDRESS:985 SUEIRROTELEPHONE:
(510) 783-1174
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 50CENSUS: 25DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH: Program Director Shirley EastmanTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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At 12:15 pm on this day, October 30, 2024, Licensing Program Analyst (LPA) Delmundo arrived an unannounced annual required inspection. LPA met with Program Director (PD) Shirley Eastman, and informed the purpose of visit.

LPA toured the facility inside out with the PD. 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 obstructions. 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 112.6 degrees Fahrenheit. Facility has 2 in one smoke and carbon monoxide detector that was tested and observed in operating condition. Facility conducts disaster drills every 3 months, and records showed last conducted August 21, 2024.

LPA reviewed 5 staff and 5 residents files. Facility does not handle clients' cash resources nor administer medications.

LPA observed the following:
-at 12:39 pm, backyard fence's wood plank coming off.



......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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: 10/30/2024
NARRATIVE
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LPA received copies of the following updated documents on this day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan
4. LIC9282 Infection Control Plan

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the PD.

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: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2024 02:45 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/30/2024 at 02:25 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: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(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.

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 backyard fence's wood plank coming off which poses a potential safety and/or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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PD stated she'll have the fence fixed. Picture to be submitted by 11/13/24.
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: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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