<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011441026
Report Date: 04/20/2021
Date Signed: 04/20/2021 02:02:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2021 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210325150713
FACILITY NAME:BROADWAY HOMEFACILITY NUMBER:
011441026
ADMINISTRATOR:DELEON, IMELDA F.FACILITY TYPE:
735
ADDRESS:6185 BROADWAY AVENUETELEPHONE:
(510) 894-3311
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:6CENSUS: 5DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Victor De LeonTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator failed to comply with current department’s policy.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/20/2021 Licensing Program Analyst (LPA) Allison O'Hollaren conducted an announced visit with Licensee Victor De Leon to deliver investigation findings on the above allegation. Due to State's current shelter in place order pertaining to COVID-19 it was not possible to perform this visit at the facility. The visit was performed by telephone.

During the course of the investigation, LPA interviewed Licensees Victor De Leon and Imedla De Leon. Licensees confirmed with LPA that the facility did not follow the department's policy on surveillance testing (PIN 20-38-ASC) in which “Facilities should conduct surveillance testing of 25 percent of all staff every 7 days.” Licensees confirmed the facility has stopped with the surveillance testing since the staff were all vaccinated. Based on records provided to LPA, all staff were tested on 12/7/2020. Licensee Victor De

Continued on LIC 9099-C...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20210325150713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROADWAY HOME
FACILITY NUMBER: 011441026
VISIT DATE: 04/20/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Leon stated that all staff were tested on 01/07/2021 but he does not have a copy of the test results and was advised by laboratory that all are negative. There are no records to show that testing was done in February.

Based on LPA’s interviews and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

The deficiency is cited per CCR Title 22. Failure to provide proof of correction by POC date may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report emailed.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20210325150713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROADWAY HOME
FACILITY NUMBER: 011441026
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2021
Section Cited
CCR
80072(a)(2)
1
2
3
4
5
6
7
Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations...
1
2
3
4
5
6
7
By POC date, Licensee will review PIN 20-38-ASC and send a copy of self-certification letter to CCLD. By POC date Licensee will also send proof that Licensee is subscribed to receive all PIN notifications.
8
9
10
11
12
13
14
to meet his/her needs. This requirement is not met as evidenced by: Based on interviews and records reviewed, facility did not conduct surveillance testing in February 2021 and Licensee states staff tested negative in January 2021 but does not have record on file. This poses a potential risk to the health and safety of clients under care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2021 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210325150713

FACILITY NAME:BROADWAY HOMEFACILITY NUMBER:
011441026
ADMINISTRATOR:DELEON, IMELDA F.FACILITY TYPE:
735
ADDRESS:6185 BROADWAY AVENUETELEPHONE:
(510) 894-3311
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:6CENSUS: 5DATE:
04/20/2021
UNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Victor De LeonTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not adhering to COVID-19 infection control
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/20/2021 Licensing Program Analyst (LPA) Allison O'Hollaren conducted an announced visit with Licensee Victor De Leon to deliver investigation findings on the above allegation. Due to State's current shelter in place order pertaining to COVID-19 it was not possible to perform this visit at the facility. The visit was performed by telephone.

During the course of the investigation, LPA interviewed two licensees, 3 staff and 2 residents.

Based on interviews with 1 resident and 3 staff, 1 out of 1 residents and 3 of 3 staff stated that all staff and licensees wear facemasks in the facility at all times.

Continued on LIC 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20210325150713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROADWAY HOME
FACILITY NUMBER: 011441026
VISIT DATE: 04/20/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on interviews conducted, LPA found the above allegation to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted with Licensee. Copy of report provided via email.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5