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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440756
Report Date: 12/09/2022
Date Signed: 12/09/2022 11:21:38 AM

Document Has Been Signed on 12/09/2022 11:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BOBBI FRENCH RESIDENTIAL CARE FACILITYFACILITY NUMBER:
011440756
ADMINISTRATOR:GOOLSBY, NORMANFACILITY TYPE:
735
ADDRESS:521 - 32ND STREETTELEPHONE:
(510) 428-9424
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 6CENSUS: 3DATE:
12/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bobbi French, LicenseeTIME COMPLETED:
11:30 AM
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On 12/9/22 at 10:00AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving a death report submitted to CCLD dated on 11/16/22. LPA explained the purpose of the visit with the licensee.

The licensee stated that client was observed change of health condition but refused to go to hospital. Licensee called ambulance anyway. Client was sent to Alta Bates Summit Hospital on 10/26/22. Licensee called hospital the next day, hospital didn't release client's information to licensee. On 10/29/22, Summit hospital called facility and asked if facility has equipment such as wheelchair or walker for client and the information of client's relative. On 11/2/22, licensee followed up with hospital again but was told that a written request of releasing client's information was required. Licensee assumed that client was sent to a skill nursing facility. Licensee faxed a written request to hospital on 11/9/22, and have not received response from hospital as of today's date visit. On 11/16/22, Licensee received a letter in mail from Social Security Administration that indicated client was passed in hospital on 11/2/22. Licensee obtained death report from the County recording office and submitted to CCLD on 11/28/22.

The licensee stated that client ate regularly. Client was a vegetarian and only ate vegetable, fruits and wheat bread what she liked. Client has been refusing to see her doctor since February 2021 was observed in the note. Licensee stated that client refused to talk to the case manager who visited her in the facility. The case manager referred client to another organization where sent out staff to visit client. Licensee stated that client also refused to talk to this staff, after 3-4 attempts, this staff stated that he would not come back to visit client again.

Future visit for further investigation may be required. Exit interview conducted with the licensee and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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