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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200186
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:02:31 PM

Document Has Been Signed on 12/10/2024 03:02 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:MCHAROLD HOMEFACILITY NUMBER:
019200186
ADMINISTRATOR/
DIRECTOR:		LORNA A.HAYAGFACILITY TYPE:
735
ADDRESS:1076 EL DORADO DRIVETELEPHONE:
(925) 245-0779
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 6DATE:
12/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Lorna Hayag, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 12/10/2024 at 2:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Case Management visit regarding an incident report received on 12/10/2024. LPA met with Administrator, Lorna Hayag and explained the purpose of the visit.

Based on the incident report received on 12/10/2024, staff checked on clients at 12:30AM on 12/9/2024 and noticed that client (C1) was not in bed. Another staff (S2) stated that C1 has been in the bathroom for about 10 minutes and another client needed to use the bathroom. Staff (S1) knocked on the door without a response and later used a key to open the bathroom door. C1 was not in the bathroom and staff noticed the side gate was open. Staff (S3) drove around the neighborhood to look for C1. Later, C1 came back to the facility.

After reviewing C1's physician's report dated 8/19/2024, it states that C1 is unable to leave the facility unassisted.

No deficiencies are being cited on this date.


Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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