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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441026
Report Date: 05/03/2024
Date Signed: 05/03/2024 03:47:11 PM

Document Has Been Signed on 05/03/2024 03:47 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:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Menchie MatalangTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On this day at around 10:15 am, LPA Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Menchie Matalang. LPA explained to Matalang the purpose of the visit. The Administrator was informed by Matalang about LPA presence and purpose of the visit. The Administrator was unable to come to the facility. She authorized Matalang to sign the report. The facility is a Level 3 home vendorized by the Regional Center of the East Bay (RCEB).

Upon arrival, LPA observed 3 clients at the facility. Two were watching TV and one client was inside the room. One client was in the day program.

During the visit, LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, kitchen/dining area, garage, and backyard. Hot water temperature measured at 105 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. Fire extinguisher that appeared full and was last serviced on 10/19/2023 was observed. Smoke detectors and carbon monoxide were tested and observed operational.

At 11am, LPA reviewed 4 client and 3 staff files. Staff are fingerprint cleared and associated to the facility. LPA interviewed the only staff on duty. Clients present were unable to communicate verbally.

At 2pm, LPA reviewed P & I money and log. At around 3pm, LPA reviewed medications and Medication Administration Record (MAR) with Matalang.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROADWAY HOME
FACILITY NUMBER: 011441026
VISIT DATE: 05/03/2024
NARRATIVE
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The following records were requested to be submitted to CCL by Monday, May 6, 2024;
  • Infection Control Plan
  • Emergency Disaster Plan
  • Lic 500
  • Roster of Clients
  • Liability Insurance
  • Surety Bond

Deficiencies were cited per Title 22 California Code of Regulations and can be found on the attached Lic 809D. A $500 civil penalty is assessed for repeat violation for today's visit.

Exit interview was conducted with Matalang and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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Document Has Been Signed on 05/03/2024 03:47 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 05/03/2024 at 03:12 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: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85095.5(a)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: 

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in not having a copy of Infection Control Plan available which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
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By POC date, the Administrator will submit to CCL the updated Infection Control Plan.
Type A
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having an updated Emergency Disster Plan which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
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By POC date, the Administrato will submit to CCL updated Emergency Disaster Plan.
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: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


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Document Has Been Signed on 05/03/2024 03:47 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 05/03/2024 at 03:12 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: 05/03/2024

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
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Based on observation, the licensee did not comply with the section cited above in having a ripped screen window in Rm1,
backyard fence with missing wood planks, closet door broken/taped which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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The Administrator will get screen window and backyard fence fixed, closet door replaced and submit photo proof to CCL by POC date.
Type B
Section Cited
CCR
85065.5(a)(1)
Day Staff-Client Ratio
(1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having one live in staff from Fri-MOnday with 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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The Administrator will ensure that there is sufficient staff to meet the needs of the clients in care by submitting plans on how to address the staffing issue 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: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


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Document Has Been Signed on 05/03/2024 03:47 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 05/03/2024 at 03:12 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: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(19)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having mold on the soap dispenser bottle which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
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The Administrator will ensure that all dishwashing soap bottles are free from mold by replacing the old soap bottles and submit photo proof to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


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