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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440781
Report Date: 04/20/2023
Date Signed: 04/20/2023 05:03:30 PM


Document Has Been Signed on 04/20/2023 05:03 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:CROUSE HOMES, INC., THEFACILITY NUMBER:
011440781
ADMINISTRATOR:LAURA A CARTERFACILITY TYPE:
735
ADDRESS:237 CHERRY WAYTELEPHONE:
(510) 317-9016
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:15CENSUS: 14DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Hilario Siwa/House ManagerTIME COMPLETED:
05:00 PM
NARRATIVE
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On this day, April 20, 2023, at 11:10 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with House Manager Hilario Siwa, and informed the reason for visit. LPA called and left message on Laura Carter's (administrator) voicemail. LPA also met with other staff, Zenaida Siwa.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining and living rooms, detached storage/office and residents' room in detached cottage. Facility has sufficient perishable and non-perishable foods. Fire extinguisher was observed fully charge with tag showed serviced December 12, 2022. Facility has carbon monoxide and smoke detector that were tested and observed functional. Hot water temperature in one of the common bathrooms was tested and measured at 118.2 degrees Fahrenheit.

LPA reviewed 10 residents and 4 staff files, and interviewed 3 residents and 2 staff. Medications were checked and compared against records.

LPA observed the following:
- at 11:37 am and 11:45 am, ripped carpet flooring between hallway and living room in the main house, and between hallway and resident's room in the detached cottage.
-complete record or LIC405 Record Of Client's/Resident's Safeguarded Cash Resources not readily available for review by LPA.


.....continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
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: CROUSE HOMES, INC., THE
FACILITY NUMBER: 011440781
VISIT DATE: 04/20/2023
NARRATIVE
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Administrator to submit the following updated documents by May 4, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

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

Deficiencies and plan and proof of corrections were discussed.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Hilario Siwa.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/20/2023 05:03 PM - It Cannot Be Edited

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: CROUSE HOMES, INC., THE
FACILITY NUMBER: 011440781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility 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 for ripped carpet flooring between hallway and living room in the main house, and between hallway and resident's room in the detached cottage which poses a potential safety and personal rights risks to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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Licensee and/or administrator to have the carpet flooring repaired or replaced and submit pictures by 5/04/23.
Type B
Section Cited
CCR
80070(d)
80070 Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

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 for not having a complete record or LIC405 Record Of Client's/Resident's Safeguarded Cash Resources readily available for review by LPA which poses potential personal rights risks to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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Administrator to complete the LIC405 for all residents, and send by 5/04/23 a self-certification indicating it's done.
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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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