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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441026
Report Date: 09/05/2024
Date Signed: 09/05/2024 04:50:18 PM

Document Has Been Signed on 09/05/2024 04:50 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/
DIRECTOR:		DELEON, IMELDA F.FACILITY TYPE:
735
ADDRESS:6185 BROADWAY AVENUETELEPHONE:
(510) 894-3311
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 4DATE:
09/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Anita TamposTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 9/5/2024, LPAs Luisa Fontanilla and Patricia Manalo arrived at the facility unannounced to conduct a case management visit and met with staff Anita Tampos. LPAs explained to Tampos the purpose of the visit.

While conducting investigation of complaint #15-AS-20240103160006, LPAs reviewed records and conducted interviews.

Based on records reviewed, LPA observed purchases of items including but not limited to towels, sheets sets, bath mats withdrawn from clients’ P&I monies. These items are considered part of basic services that the facility should provide to the clients and not charged to the clients.

Deficiency is cited per Title 22 California Code of Regulations. (See Lic 809D)

Exit interview was conducted with the Tampos and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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 09/05/2024 04:50 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 09/05/2024 at 04:24 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: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
CCR
80026(f)

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80026(f) Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(f) The licensee or employee of a licensee shall not make expenditures from clients' cash resources for any basic services in these regulations, or for any basic services identified in a contract/admission agreement between the client and the licensee.
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A Non Compliance Conference (NCC) is scheduled on September 19, 2024.
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This requirement is not met as evidenced by: Based on record review conducted, the facility made purchases from clients’ P&I money for towels, bed sheets, bath mats which are part of the basic services that should be provided by the facility.
By POC date, the Administrator will reimburse clients whose monies were used to purchase items that are part of the basic services. The Administrator will provide LPA a copy of the name of clients/amount reimbursed by POC date.
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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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
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