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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600218
Report Date: 03/21/2024
Date Signed: 03/21/2024 02:54:45 PM

Document Has Been Signed on 03/21/2024 02:54 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:HAYWARD EMPLOY AMERICAFACILITY NUMBER:
015600218
ADMINISTRATOR:GARRETTE, ELECIAFACILITY TYPE:
775
ADDRESS:2483 INDUSTRIAL PARKWAYTELEPHONE:
(510) 785-2284
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 30CENSUS: 22DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ebonie Lemi/Program Director TIME COMPLETED:
03:00 PM
NARRATIVE
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At 10:00 a.m., on this day, March 21, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Program Director (PD) Ebonie Lemi, and informed the reason for visit.

Facility has LIC9283 Infection Control Plan, copy of which was submitted and received by LPA on March 6, 2023.

LPA toured the facility inside out with PD. The facility is a two level building. LPA inspected the common areas, quiet room, library, media, computer and activity rooms, maintenance storage cabinet, parking area.

Clients are provided snacks and they bring their own lunch. LPA observed sufficient supplies of snacks. Activity materials were observed sufficient for clients' use.

Facility has working carbon monoxide and smoke detector. Fire extinguisher checked, observed fully charge, and tag showed serviced April 20, 2023. Facility conducts disaster drills monthly, and records showed last conducted March 8, 2024. Water temperature in one of the toilets was tested and measured at 108 degrees Fahrenheit. Room temperature was at 69 degrees Fahrenheit.

LPA reviewed 5 staff and 5 clients files, and interviewed 2 staff and 3 clients. Facility does not handle clients' P&I and does not administer medications.

LPA observed the following:
-at 10:25 a.m., trash cans without lids.
.....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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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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: HAYWARD EMPLOY AMERICA
FACILITY NUMBER: 015600218
VISIT DATE: 03/21/2024
NARRATIVE
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-at 10:29 a.m., broken cabinet door in one of the activity rooms.
-at 10:34 a.m., cleaning supplies in cabinet without lock and in unlocked staff room.
-at 11:45 a.m., S1 has no LIC503 Health Screening and TB test on file.
-at 12:00 p.m., staff (S2 and S4) no First Aid certificate on file.

Program Director to submit updated copies of the following by April 4, 2024:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)

Deficiencies are cited per Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of correction were discussed with PD.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/21/2024 02:54 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/21/2024 at 02:09 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: HAYWARD EMPLOY AMERICA
FACILITY NUMBER: 015600218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 cleaning supplies in unlocked cabinet and staff room which pose an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
1
2
3
4
Staff removed the items from the cabinet and locked the staff room.
In addition, PD to in-service the staff, and submit copy of training topic with attendees signatures by 3/22/24.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/21/2024 02:54 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/21/2024 at 02:09 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: HAYWARD EMPLOY AMERICA
FACILITY NUMBER: 015600218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

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 trash cans without lids.
which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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PD stated she'll have the staff purchase trash cans with lid. Proof of purchase and pictures to be submitted by 4/04/24.
Type B
Section Cited
CCR
82065(g)(1)
Personnel Requirements
(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in S1 not having LIC503 Health Screening and TB test on file which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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PD to have health screening and TB test completed, and submit proof by 4/04/24.
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/21/2024 02:54 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/21/2024 at 02:09 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: HAYWARD EMPLOY AMERICA
FACILITY NUMBER: 015600218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation from persons qualified by agencies including, but not limited to, the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in staff (S2 and S4) not having First Aid certificates on file which pose a potential safety and/or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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2
3
4
PD stated she'll have the staff trained. Copies of certificates to be submitted by 4/04/24.
Section Cited
Deficient Practice Statement
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
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