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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200119
Report Date: 06/04/2024
Date Signed: 06/04/2024 02:35:30 PM

Document Has Been Signed on 06/04/2024 02:35 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/
DIRECTOR:		PASCUAL, ANGELA SFACILITY TYPE:
735
ADDRESS:156 GLORIA STREETTELEPHONE:
(510) 886-2878
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Angela Pascual, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 6/4/24, Licensing Program Analyst (LPA) Kelly Nguyen arrived at the facility to conduct an annual required inspection and met with administrator (AD), Angela Pascual and explain the purpose of the visit.

LPA observed the facility do not have any staff nor clients. LPA called administrator later arrived at 11am. Ad stated that while clients are in program the facility is left unattended from 11am-1pm.

Facility was observed clean and odor free. Hot water measured at 105.1 degrees Fahrenheit. Sufficient supply of perishable and nonperishable foods were observed.

There was supply of hygiene products, warm blankets, sheets and towels. Hallways and passageways were observed free of obstruction. Carbon monoxide and smoke detectors were tested and observed functional. There was a covered aquarium observed in the dining room.

LPA reviewed 4 client records and 3 staff records. First aid kit was complete. P & I money and log was verified and observed accurate and updated.


Report continue on LIC 809C...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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 5
Document Has Been Signed on 06/04/2024 02:35 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 06/04/2024 at 01:50 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: MISSION HOPE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above by hvaing 4 knifes and three scissors left underneath the kitchen sink on the left side cabinet unknock. LPA observed the back shed have a lock pad but was not lock. Inside shed: 5 cans of paint, sharp, and chemical, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2024
Plan of Correction
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Administrator lock knifes, scissors, and lock the lock pad during the visit. Decficency Cleared.
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having the client medication left unlock on the bottom medication cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2024
Plan of Correction
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Administrator lock client medication during the visit. Decficenty Cleared.
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: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2024 02:35 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 06/04/2024 at 01:50 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: MISSION HOPE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(b)(1)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having non-slip mat in clients shared bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator will purchase a nonslip mat and provide photo to CCLD by POC date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having a treadmill in the middle of the pathway leading to the emergency exit gate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2024
Plan of Correction
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Administrator remove the treadmill during inspection. Deficiency clear.
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: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/04/2024 02:35 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 06/04/2024 at 01:50 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: MISSION HOPE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by not having a cover for the fire place in the living room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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Administrator cover the fireplace. Defficiency Cleared.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
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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: 06/04/2024
NARRATIVE
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Deficiencies were observed:

At 11:30am LPA observed living room fire place does not have a cover.
At 11:45pm LPA observed client medication was left unlock on the bottom medication cabinet.
At 11:55am LPA observed in clients shared bathroom without an non-skit mat.
At 12:45pm LPA observed 4 knifes and three scissors left underneath the kitchen sink on the left side cabinet. LPA observed the back shed have a lock pad but was not lock. Inside shed: 5 cans of paint, sharp, and chemical.
At 1:05pm LPA observed a treadmill in the middle of the pathway leading to the emergency exit gate.


Deficiencies is cited from Title 22 California Code of Regulations (see 809Ds). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

An exit interview is conducted and a copy of this report, and appeal right provided to administrator via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC809 (FAS) - (06/04)
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