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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
011441026
Report Date:
06/21/2023
Date Signed:
06/21/2023 03:28:32 PM
Document Has Been Signed on
06/21/2023 03:28 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 HOME
FACILITY NUMBER:
011441026
ADMINISTRATOR:
DELEON, IMELDA F.
FACILITY TYPE:
735
ADDRESS:
6185 BROADWAY AVENUE
TELEPHONE:
(510) 894-3311
CITY:
NEWARK
STATE:
CA
ZIP CODE:
94560
CAPACITY:
6
CENSUS:
4
DATE:
06/21/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:45 AM
MET WITH:
Imelda De Leon, Licensee
TIME COMPLETED:
03:50 PM
NARRATIVE
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On this day at around 10:45 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA spoke with Administrator Victor De Leon on the phone to inform him about the purpose of visit. Licensee Imelda De Leon arrived at the facility at a later time.
During the visit, LPA inspected the facility inside and out including but not limited to 3 client bedrooms and 2 bathrooms. Carbon monoxide and smoke detectors were tested and observed operational. First aid kit was observed completed. Hot water measured at 106 degrees Fahrenheit. There were no bodies of water observed.
The following deficiencies were observed:
1. LPA observed C3 unable to ambulate independently
2. there was insufficient supply of nonperishable foods
3. floor was observed sticky, window in Room 4 dusty, has urine smell
Deficiencies are cited per Title 22 California Code of Regulations (see Lic 809D).
Exit interview was conducted with Administrator. Appeal Rights and a copy of this report were provided.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/21/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
5
Document Has Been Signed on
06/21/2023 03:28 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
06/21/2023
at
02:35 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:
06/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. Client 3 (C3) was observed unable to ambulate on her own; needed staff assistance in ambulating
POC Due Date:
06/22/2023
Plan of Correction
1
2
3
4
By POC date, Administrator will submit letter request for nonambulatory fire clearance and facility sketch.
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. C3 was observed unable to ambulate independently and needed staff assistance when ambulating which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/22/2023
Plan of Correction
1
2
3
4
Licensee will send in request for non ambulatory fire clearance by POC date.
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:
06/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
06/21/2023 03:28 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
06/21/2023
at
02:35 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:
06/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)(1)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients. (1) Clients whose condition becomes nonambulatory shall not use rooms or areas restricted to ambulatory clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having C3 who is unable to ambulate independently without an approved non ambulatory fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/22/2023
Plan of Correction
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2
3
4
Licensee will submit request for nonambulatory fire clearance by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
06/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
06/21/2023 03:28 PM
- It Cannot Be Edited
Created By:
Luisa Fontanilla
On
06/21/2023
at
02:35 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:
06/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed floors were sticky, window in Room4 dusty, mold in staff bathroom and that facility has urine smell which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/30/2023
Plan of Correction
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2
3
4
Administrator will have house cleaners clean facility and notify LPA once completed.
Type B
Section Cited
CCR
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:
Deficient Practice Statement
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2
3
4
Based on observation , the licensee did not comply with the section cited above in not having sufficient supply of nonperishable foods which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/23/2023
Plan of Correction
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4
Administrator will purchase additional nonperishable foods with different varieties.
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:
06/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2023
LIC809
(FAS) - (06/04)
Page:
4
of
5