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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441026
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:35:13 PM

Document Has Been Signed on 02/14/2024 03:35 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
E BAY DELTA AC/SC, 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:
02/14/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Anita Tampos, CaregiverTIME COMPLETED:
03:40 PM
NARRATIVE
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On 02/14/2024 at 1:20PM, Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management Health and Safety check as a result of the department having an informal meeting with Licensees, Victor and Imelda de Leon on 02/13/2024. LPA met with Caregiver, Anita Tampos and explained the purpose of the visit. Anita phoned Licensee/Administrator, Imelda de Leon to inform. LPA spoke with Imelda de Leon and advised that LPA was conducting a health and safety check today.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 110.6 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were non-sufficient. Resident's medications were kept locked in cabinet. First-aid kit was not complete. Fire extinguisher was observed to be full and last serviced on 10/19/2023. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.



LIC 809 Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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Document Has Been Signed on 02/14/2024 03:35 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 02/14/2024 at 02:06 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: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2024
Section Cited
CCR
85076(d)(1)

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85076(d)(1) Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
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Administrator agreed to purchase food and submit receipts and photos of food purchases to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above in having 7-day non-perishable and 2-day perishable foods which poses a potential health, safety or personal rights risk to persons in care.
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Type B
02/16/2024
Section Cited
CCR87555(b)(8)

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87555 General Food and Service Requirements
(b) The following food service requirement shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
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Licensee agreed to inventory all food supply in refrigerator, freezer and cabinets and toss expired/rotten food items. Send photos to CCLD by POC due date.
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Based on observation, the licensee did not comply with the section cited above in having rotten apples, lemons and oranges in baskets located in dining area which poses a potential health, safety or personal rights 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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROADWAY HOME
FACILITY NUMBER: 011441026
VISIT DATE: 02/14/2024
NARRATIVE
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LIC 809-C Continued...

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 1:45PM rotten apples, lemons, oranges located in baskets near TV.
  • At 1:50PM lack of canned goods, tuna, eggs, pasta, veggies, and fruits in pantries, refrigerators and freezers.
  • At 2:00PM missing bandages in first aid kit.

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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/14/2024 03:35 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 02/14/2024 at 03:08 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: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2024
Section Cited
CCR
87465(a)(8)

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87465 Incidental Medical and Dental Care

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
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Administrator will buy a completed first ait kit that contains all of the reqiuired items and submit photographic proof to CCL by POC date
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Based on observation, the licensee did not comply with the section cited above in having a complete first aid kit which poses a potential health, safety or personal rights 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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


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