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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440823
Report Date: 05/26/2022
Date Signed: 05/26/2022 02:37:49 PM

Document Has Been Signed on 05/26/2022 02:37 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:BESCO GARDENFACILITY NUMBER:
011440823
ADMINISTRATOR:LAGUNA, ROBERT I.FACILITY TYPE:
735
ADDRESS:40242 CROCKETT STREETTELEPHONE:
(510) 226-8813
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 3DATE:
05/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Adminsistrator, Robert LagunaTIME COMPLETED:
02:45 PM
NARRATIVE
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On 5/26, 2022 at 1:45PM, Licensing Program Analysts (LPAs), L. Fici and L. Hall arrived unannounced to conduct a case management visit. LPAs met with Administrator, Robert Laguna and explained the reason for the visit.

While LPAs were conducting an annual inspection LPAs observed that bedroom #2 had belongings of C1 was occupied by belongings. LPAs reviewed C1's file and observed P & I money. S1 and S2 stated that C1 no longer resides at the facility. C1 was hospitalized on 9/2/2021 and will not return. Facility did not report C1's hospitalization to CCLD

The following deficiency was observed:

-At 11:45 LPAs reviewed C1's file and did not observe LIC624 for incident.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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Document Has Been Signed on 05/26/2022 02:37 PM - It Cannot Be Edited


Created By: Liridon Fici On 05/26/2022 at 01:55 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: BESCO GARDEN
FACILITY NUMBER: 011440823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2022
Section Cited
CCR
80061(b)

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80061 Reporting Requirements (b) Upon the occurrence,... (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement was not met as evidence by:
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Administrator agreed to review the regulation and submit a self-certification to CCLD by POC date.
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LPA observed that the Licensee did not follow the section cited above in reporting the incident to CCLD, which poses a potential health and safety risk to persons in care.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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