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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440781
Report Date: 07/02/2024
Date Signed: 07/02/2024 01:02:21 PM

Document Has Been Signed on 07/02/2024 01:02 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/
DIRECTOR:		LAURA A CARTERFACILITY TYPE:
735
ADDRESS:237 CHERRY WAYTELEPHONE:
(510) 317-9016
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 15CENSUS: 14DATE:
07/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Laura Carter/Administrator TIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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At 11:30 a.m. on this day, July 2, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Special Incident Report (SIR) for resident (R1) submitted by the facility. No one was at the facility when LPA arrived. LPA called and spoke over the phone with Laura Carter, administrator, and informed the reason for visit. Administrator arrived after about 13 minutes.

LPA obtained and reviewed R1's LIC602 Physician's Report, Individual Program Plan and LIC625 Appraisal/Needs and Services Plan

SIR indicated that on 6/05/24 at approximately 5:00 p.m., the house manager (S1) received a phone call from R1's day program saying R1 just arrived and that R1's missed the bus in the morning and walked to the day program. R1 looked exhausted and R1's arms, face/neck were sunburned. Upon returning to the facility, staff noticed R1's ankles and legs sunburned and has blisters under his toes. S1 contacted the transportation company and was told they called 5 times to say they were at the house waiting for R1. S1 checked his phone and saw only 1 call from the transportation company.

LPA conducted interview. Administrator confirmed R1 sustained blisters and the blisters are now healed. Administrator stated S1 was off on the day of the incident and it was staff (S2 and S3) who were on duty that day.

Review of R1's LIC602 revealed R1 can not leave the facility unassisted.



.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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: CROUSE HOMES, INC., THE
FACILITY NUMBER: 011440781
VISIT DATE: 07/02/2024
NARRATIVE
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Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. A $500.00 civil penalty is assessed on this day for deficiency section 80078(a), and will continue for $100.00 per day until corrected.

Deficiency, plan and proof of correction and civil penalty were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2024 01:02 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/02/2024 at 12:31 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: CROUSE HOMES, INC., THE
FACILITY NUMBER: 011440781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2024
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision:
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

-This requirement is not met as evidenced by:
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Administrator to do the following, and submit proof by 7/03/24:
1. Come up with a plan on ensuring residents are properly assisted when picked-up going to the day program.
2. in-service the staff and ensure the plan is followed.
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-Based on records review and interview, the licensee did not comply with the section above when R1 walked to the day program without the staff's knowledge and R1's LIC602 showed R1 can not leave the facility unassisted which posed an immediate risk to person in care. Civil penalty is assessed.
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A $500.00 civil penalty is assessed.

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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: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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