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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600144
Report Date: 03/24/2023
Date Signed: 03/24/2023 11:27:25 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/17/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20230317162424
FACILITY NAME:HODGES RESIDENTIAL FACILITYFACILITY NUMBER:
015600144
ADMINISTRATOR:HODGES, A., C., & T.FACILITY TYPE:
735
ADDRESS:3320 LOMA VISTA WAYTELEPHONE:
(510) 536-0998
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:6CENSUS: 5DATE:
03/24/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Anthony Gray, CaregiverTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff did not follow proper reporting requirements
INVESTIGATION FINDINGS:
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On 3/24/23 Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a complaint investigation for the above allegation starting at 10:15am. LPA was greeting by Anthony Grey, caregiver. LPA spoke with administrator Anthony Hodges to explain the purpose of the visit and get verbal permission for Anthony Grey to sign the report.

It was alleged that Staff did not follow proper reporting requirements: At 10:20am LPA spoke with Administrator to confirmed if administrator submitted an unusual incident report to CCLD upon the incident that happened on 8/13/22. Administrator confirmed with LPA that there was no confirmation, or any documentation of faxing an unusually incident report to CCLD on 8/13/2022. Therefore, the allegation is SUBSTANTIATED.

Report continue on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20230317162424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HODGES RESIDENTIAL FACILITY
FACILITY NUMBER: 015600144
VISIT DATE: 03/24/2023
NARRATIVE
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Based on LPAs recorded reviews, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 1), are being cited on the attached LIC 9099D.

A copy of this report and appeal right is provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20230317162424
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HODGES RESIDENTIAL FACILITY
FACILITY NUMBER: 015600144
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
80061(b)
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80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement was not met as evidence by:
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LPA discussed POC with Administrator, and he agrees to review the regulation, and submit a self-certification to CCLD by POC date.
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Based on record reviewed and interviewed with administrator. It was confirmed by the administrator that there was no proof or confirmation that an unusual incident report was sent to CCLD on 8/13/22, which poses a potential health and safety risk to the clients 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3