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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200119
Report Date: 09/14/2022
Date Signed: 09/14/2022 03:44:51 PM

Document Has Been Signed on 09/14/2022 03:44 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:MISSION HOPE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200119
ADMINISTRATOR:JINO GAMEZFACILITY TYPE:
735
ADDRESS:156 GLORIA STREETTELEPHONE:
(510) 886-2878
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 3DATE:
09/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Angela Pascual/Lead StaffTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management inspection in regards to Special Incident Report (SIR) submitted by the facility and forwarded to LPA on Monday, September 12, 2022. The SIR indicated that on September 4, 2022, resident (R1) was observed by staff (S1) wheezing and coughing. S1 called R1's Physician Assistant (PA) who advised to check R1's
blood pressure and oxygen level which were measured at normal level. PA advised if the oxygen level goes below the normal range, to bring R1 to the emergency. After an hour and a half, S1 went to R1's bedroom while on the phone with PA to update PA on R1's condition. R1 vomited followed by bluish tinge on the skin. Staff immediately called 9-1-1 and performed CPR. The paramedics arrived and took over performing CPR.and declared that R1 passed away.

On this day, September 14, 2022, LPA met with staff, Angela Pascual, Fely Orejudos abd Julie Fe Suyat. . LPA called and spoke with Jino Gamez, administrator, over the phone and informed the reason for visit. Gamez stated he can not come to the facility and authorized Pascual to sign and receive this report.

LPA conducted interviews and reviewed R1's file. LPA obtained copies of the following R1's documents:
1. Face Sheet
2. Admission Agreement
3. Physician's Report dated 2022
4. Annual Review
5. PA's In-House Monthly Visits
6. Home Health Visit Notes
7. Medication Administration Record
7. Hospital Discharge document
8. Death Report
...continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MISSION HOPE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200119
VISIT DATE: 09/14/2022
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Administrator to submit/provide to LPA a copy of death certificate once becomes available.

No deficiencies cited on this day.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
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