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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600218
Report Date: 03/06/2025
Date Signed: 03/06/2025 02:34:20 PM

Document Has Been Signed on 03/06/2025 02:34 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/
DIRECTOR:		GARRETTE, ELECIAFACILITY TYPE:
775
ADDRESS:2483 INDUSTRIAL PARKWAYTELEPHONE:
(510) 785-2284
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 30CENSUS: 18DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Ebonie Lemi/Program Director TIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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On this day, March 6, 2025, at 10:45 am, 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.

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. Activity materials were observed sufficient for clients' use.

Facility has working carbon monoxide and smoke detectors. Fire extinguishers checked, observed fully charge, and tags showed serviced 1/16/25. Facility conducts disaster drills, and records showed last conducted 1/31/25. Water temperature in one of the toilets was tested and measured at 115.1 degrees Fahrenheit. Room temperature was at 72.6 degrees Fahrenheit.

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

LPA observed the following:
-at 11:05 am, client (C1) was out in the facility's open parking lot sunbathing without staff supervision. C1's LIC602A revealed C1 can not leave the facility unassisted and has wandering behavior.

.....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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 3
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: 03/06/2025
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LPA obtained copies of the following updated/current documents:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)

Deficiency is cited per Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency 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: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 02:34 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/06/2025 at 02:15 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: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80077.3(a)
80077.3 Care for Clients Who Lack Hazard Awareness or Impulse Control
(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in C1 able to go out ot the parking lot unnoticed by the staff which poses an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Program Director stated she'll do the following. Proof to be submitted by 3/07/25:
1. In-service the staff.
2. Call for a meeting with RCEB and C1's care home.
3. Update the Individual Service Plan.
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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