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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600456
Report Date: 12/20/2024
Date Signed: 12/20/2024 12:33:28 PM

Document Has Been Signed on 12/20/2024 12:33 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LAHANA WAY HOMEFACILITY NUMBER:
015600456
ADMINISTRATOR/
DIRECTOR:		TERESITA MCLAUGHLINFACILITY TYPE:
735
ADDRESS:39648 LAHANA WAYTELEPHONE:
(510) 490-3283
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 6DATE:
12/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH: Bernadeth Relon, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 12/20/2024 at 11:30 AM, Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla arrived unannounced to conduct a Case Management regarding a self-reported incident that occured on 11/25/2024. Administrator, Bernadeth Relon, self-reported to CCLD on 11/27/2024. LPAs met with Administrator, Bernadeth Relon, and explained the purpose of the visit.

LPAs reviewed C1's Physician's Report, Medication Administrator Record (MAR), Hospital Discharge Summary, Discontinued Medication Order, and Medication order from 2012.

LPAs interviewed Administrator. Administrator states that C1 did not fall. Administrator phoned the pharmacy and was able to get the order for Fosamax from 2012. C1 has been on long-term use of Fosamax and was discontinued on December 2024. C1 was prescribed a different medication to replace Fosamax. Administrator states that they were advised by the doctor that long-term use of Fosamax can make bones brittle.

LPAs interviewed C1. C1 denied falling and denied pain in their ankle. C1 states that C1 is happy and likes living at the facility.

No deficiencies cited during visit. Exit interview was conducted with Administrator, and a copy of this report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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