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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601167
Report Date: 01/29/2021
Date Signed: 01/29/2021 03:50:45 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
FACILITY NAME:PALM TREE COURTYARDFACILITY NUMBER:
015601167
ADMINISTRATOR:JULIANA TABURAZAFACILITY TYPE:
740
ADDRESS:550 DEAN STREETTELEPHONE:
(510) 538-7428
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:15CENSUS: 7DATE:
01/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Juliana Taburaza/AdministratorTIME COMPLETED:
03:45 PM
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On January 28, 2021, Licensing Program Analyst (LPA) Delmundo received an e-mail from Juliana Taburaza, administrator, stating that at around 11:00 a.m on January 27, 2021, staff observed resident (R1) was not at the facility. R1 skipped his lunch and staff thought that he was walking in the neighborhood as he always does daily. R1 is always in and out walking in the community and occasionally using his room’s exit door coming in and going out. R1 did not come home that day. The following day, January 28th, staff called the police and reported R1 is missing.

On this day, January 29, 2021, Licensing Program Analyst (LPA) Delmundo conducted a case management with Ms. Taburaza. LPA informed her that the purpose of the case management is regarding the incident she reported to LPA. and that due to directive by management to telework, it is is done via televisit.

LPA conducted interviews. LPA requested for a copy of Physician's Report which revealed R1 can leave the facility unassisted. R1 came back to the facility on the night of January 28th.

No deficiency cited on this day.

Exit interview conducted and copy of this report provided to Ms. Taburaza via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
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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