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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600386
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:38:57 PM

Document Has Been Signed on 12/17/2024 03:38 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HARTNELL HOME CAREFACILITY NUMBER:
015600386
ADMINISTRATOR/
DIRECTOR:		PURUGANAN,VICTORIA C.FACILITY TYPE:
740
ADDRESS:2041 HARTNELL STREETTELEPHONE:
(510) 489-7290
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 3DATE:
12/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Jezrael Pascual, House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 12/17/2024 at 10:20 AM Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a Case Management visit. LPAs met with Caregivers, Paciencia, Winnie and Cesar. House Manager, Jezrael Pascual, arrived approximately, 1 hour later. Administrator, Victoria Puruganan was not available.

While LPA L. Alexander and K. Nguyen was conducting a complaint investigation(15-AS-20241213161313) on 12/17/2024. During investigation LPAs observed a chain lock attached to the inside door. LPAs advised caregivers that a chain lock can't not be attached and hooked on the doors in preventing residents from leaving out the door.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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 2
Document Has Been Signed on 12/17/2024 03:38 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 12/17/2024 at 11:17 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: HARTNELL HOME CARE
FACILITY NUMBER: 015600386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2024
Section Cited
CCR
87468.1(a)(6)

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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly... personal rights:
(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises.... This does not prohibit a with permission from the Department.

This requirement is not met as evidence by:
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Administrator agreed to remove the chain latch from front door. During visit, chain was removed. Deficiency cleared.
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This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the section cited above by having a door chain latch at front door which poses an immediate health and safety risk to the persons in care.
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An immediate civil penalty of $500 is assessed today.

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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:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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