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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 03:17:45 PM

Document Has Been Signed on 12/17/2024 03:17 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: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 - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Jezrael Pascual, Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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During a complaint investigation (15-AS-20241213161313) on 12/17/24. During staff interview Program Analysts (LPAs) K. Nguyen and L. Alexander discovered Administrator (ADM) Victoria Puruganan is not at the facility a minimum of 20 hours a week according to Administrator qualification. LPAs reviewed LIC 500 indicates ADM are present at the facility from Monday- 9am-3pm, Tuesday- 8am-2pm, Wed 9am-2pm, and as needed. Staffs stated within the month of November ADM showed up a maximum of three time. ADM gave permission for Jezrael to sign the report from the beginning of the visit.

*An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month. *

Exit interview conducted. A copy of the LIC421FC, this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
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)
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Document Has Been Signed on 12/17/2024 03:17 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 12/17/2024 at 03:02 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: 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 B
12/24/2024
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties
All facilities shall have a qualified and currently certified administrator... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section... This requirement is not
as evidenced by:
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Licensee/ Administrator agrees to have a set hour dedicated at the facility to handle daily administrator daily operation. Licensee/ Administrator agree to have a record of time in and out sign along with staff signature witness ADM at the facility according to the ADM set time submit on a weekly basic starting 12/23/24 CCLD by POC date.
*An immediate $250.00 civil penalty will be assessed on today's date for reported violation within 12month. *
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Based on inteviews, the licensee did not comply with the section cited above by not having the administrator at the facility for a sufficient number of hours which poses an immediate health and safety risk to persons 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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
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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