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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601083
Report Date: 07/13/2022
Date Signed: 07/21/2022 10:17:03 AM


Document Has Been Signed on 07/21/2022 10:17 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/17/2022 10:06 PM

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

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This is an amendment to the original 809 issued on 7/13/2022.

On 07/13/2022 at 9:50 AM Licensing Program Analysts (LPAs) C. Fowler and L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 07/10/2022. LPA met with Administrator Dolly Rizvi and explained the purpose of the visit.

Incident report dated 7/10/2022 revealed Resident 1 (R1) jumped from the 3rd floor of the facility.

During visit LPAs interviewed ED Dolly Rizvi, S2. S3, collected and reviewed documents, and toured four (4) rooms in memory care. During interview ED Dolly Rizvi stated she conducted an over-the-phone assessment with Kaiser prior to R1 being admitted into the facility on 07/08/2022. ED Dolly Rizvi stated she was not aware that R1 had suicidal ideations.

Further investigation needed.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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