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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200158
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:16:04 PM

Document Has Been Signed on 07/06/2023 04:16 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:MISSION HOPE DAY PROGRAM- HAYWARDFACILITY NUMBER:
019200158
ADMINISTRATOR:JAY FRANCIS Y GAMEZFACILITY TYPE:
775
ADDRESS:21328 MISSION BLVD.TELEPHONE:
(510) 888-9231
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 45CENSUS: 18DATE:
07/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Charlie OlivarTIME COMPLETED:
04:20 PM
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On 7/6/2023 at 2:40 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit regarding an Incident Report received on 7/3/2023. LPA met with Charlie Olivar, Program Director (PD) and explained the purpose of the visit.

During visit, LPA requested the following documents: Individualized program plan (IPP), Individualized service plan (ISP), admission agreement, annual evaluation report, semiannual evaluation report, and face sheet. LPA interviewed the facilities program director about the incident that occurred on 6/30/2023.

Incident report dated Friday, 6/30/2023, revealed by PD that client 1 (C1) was interacting with staff and looked fine during the communities outing at Gordon E. Oliver Eden Park; C1 did not appear weak by staff. At approximately 11:30AM, clients were eating their lunch, however C1 did not have an appetite and asked S1 to be taken to the restroom. After C1 went to the restroom, client suddenly became weak and S1 observed C1 not walking well while leaving the restroom. S1 took C1 to the van and C1 became weaker. C1 was not able to get into the van and laid on the floor of the van. C1 was not responsive. At approximately 12:20PM, PD was called via facetime by S1 and PD advise S1 to call 911 immediately. S1 was directed by 911 to performed CPR on C1 until the paramedics arrived. At approximately 12:27PM, paramedics arrived and continued CPR. At 1:01PM, paramedics declared C1 deceased.

There were no deficiencies cited during today visit.

Exit interview conducted with PD, and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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