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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441026
Report Date: 06/06/2022
Date Signed: 06/06/2022 02:13:03 PM

Document Has Been Signed on 06/06/2022 02:13 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: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: 4DATE:
06/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Menchie Matalang, CaregiverTIME COMPLETED:
02:20 PM
NARRATIVE
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On 6/6/2022 at 1:45PM Licensing Program Analysts (LPAs) L. Hall and L. Fici arrived unannounced to conduct a Case Management. LPA met with Menchie Matalang, Caregiver and explained the reason for the visit. LPA. L. Hall spoke with Imelda De Leon, Administrator and approval was given for Caregiver to sign documents.

While LPA L. Hall was conducting a complaint investigation 15-AS-20200508131152 on 5/5/2022 during record review LPA observed C1’s file was missing documents. LPA requested IPP (Individual Program Plan), ISP (Individual Service Plan), and behavioral assessment from Administrator. Administrator stated documents have been moved to storage off the premises of the facility.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.



Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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 06/06/2022 02:13 PM - It Cannot Be Edited


Created By: Laura Hall On 06/06/2022 at 01:49 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: BROADWAY HOME
FACILITY NUMBER: 011441026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2022
Section Cited
CCR
80087(g)

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80070 Client Records (g) Original client records... shall be retained for at least three years following termination of service to the client. This requirement was not met as evidence by:
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Administrator agreed to review Regulation 80070 Client records and submit a self-certification that the regulation has been reviewed and administrator will abide by the regulation going forward. Self-certification will be submitted by the POC date.
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Based on LPAs observation and records review the Licensee did not comply with the section cited above in maintaining C1's records following termination of service, 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022


LIC809 (FAS) - (06/04)
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