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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600144
Report Date: 03/04/2022
Date Signed: 03/04/2022 11:56:46 AM

Document Has Been Signed on 03/04/2022 11:56 AM - 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: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:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Anthony Hodges, AdministratorTIME COMPLETED:
12:10 PM
NARRATIVE
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On 3/4/2022 starting at 8:15 a.m., Licensing Program Analyst (LPAs) Catherine Lin and Kelly Nguyen arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator Anthony Hodges and disclosed the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Mitigation Plan on file.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· At 8:30 a.m., LPAs observed unlocked knives and cleaning solutions in the kitchen, Staff locked up all items during inspection.
· At 8:31 a.m., LPAs observed centrally stored medications unlocked and key was left on the lock. Staff locked up the store and removed the key from the lock during inspection.
· At 9:30 a.m., LPAs observed a broken window by the front door and a window in a client's room downstairs has 1' gap. LPAs also observed a pullout drawer in the kitchen has no pull handle and no stopper to prevent from dropping.

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

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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 03/04/2022 11:56 AM - It Cannot Be Edited


Created By: Catherine Lin On 03/04/2022 at 11:08 AM
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: HODGES RESIDENTIAL FACILITY
FACILITY NUMBER: 015600144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above, where medication cabinet was unlocked which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Staff locked up the medication cabinet during inspection.
In Addition, Administrator agreed to provide in-service training of regulation to staff, and submit copies of training agenda and sign-in sheet to CCL by the POC due day.
Type B
Section Cited
CCR
80087(g)(1)
80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above, where knife and cleaning solutions in the kitchen were unlocked which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Staff locked up knife and cleaning solutions during inspection.
In addition, Administrator agreed to provide in-service training of regulation to staff, and submit copies of training agenda and sign-in sheet to CCL by the POC due day.
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:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2022 11:56 AM - It Cannot Be Edited


Created By: Catherine Lin On 03/04/2022 at 11:21 AM
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: HODGES RESIDENTIAL FACILITY
FACILITY NUMBER: 015600144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings 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 and interview, the licensee did not comply with the section cited above, one broken window by the front door, one window in a client's room downstairs, and a broken drawer in the kitchen were unrepaired which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Administrator agreed to repair the windows and drawer, and submit photos to CCL by the POC due day.
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:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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