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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200191
Report Date: 05/05/2023
Date Signed: 05/05/2023 06:12:08 PM

Document Has Been Signed on 05/05/2023 06:12 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:CEDAR HOME AT NILES GROVEFACILITY NUMBER:
019200191
ADMINISTRATOR:TRAN, MONIQUE NFACILITY TYPE:
735
ADDRESS:35525 NILES BLVD.TELEPHONE:
(510) 818-0716
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 6DATE:
05/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Edith Sarmiento, AdministratorTIME COMPLETED:
06:20 PM
NARRATIVE
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On 5/5/2023 at 4:35 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit regarding an Incident Report received on 3/9/2023. LPA met with Edith Sarmiento, Administrator (Adm) and explained the purpose of the visit.

During visit, LPA interviewed one (1) staff and C1 about the incident that took place on Monday, 2/27/2023. S1 stated on Monday, 2/27/2023, C1 was accidentally hit by the van door when client was being dropped off at day program trying to get out of the van.There was no witnesses that seen the incident. On 2/27/2023, client told her niece about the incident and clients niece emailed Monique Tran, administrator the same day the incident occurred. Client's niece scheduled an appointment to see a doctor on Monday, March 6, 2023, and on Tuesday, March 7, 2023, it indicated that client has a T12 fracture on her spine. Client did not tell staff about the incident because client was not in pain.

While interviewing C1, C1 stated that client fell out of the van while trying to get out on Monday, 2/27/2023. Client stated she fell out of the van and hurt her shoulder and back and could not get up. Client stated there were no witnesses that seen the incident occur. On Monday, March 6, 2023 clients niece scheduled an appointment to see her doctor and on Tuesday, March 7, 2023, a CT scan indicated a fracture on the spine of the client. Client stated to LPA that staff did not hurt the client and the client fell out of the van trying to go to her day program.


Continue on Lic809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CEDAR HOME AT NILES GROVE
FACILITY NUMBER: 019200191
VISIT DATE: 05/05/2023
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LPA obtained the following documents during visit: discharge notes, physicians report, and Individualized Program Plan (IPP) for C1.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

At 5:05 PM, LPA observed the facility failed to submit an SIR related to an incident that occurred on Monday, 2/27/2023 to CCL on a timely manner.


Exit interview conducted with Adm, and a copy of this report provided along with appeal rights.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
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Document Has Been Signed on 05/05/2023 06:12 PM - It Cannot Be Edited


Created By: Liridon Fici On 05/05/2023 at 05:57 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: CEDAR HOME AT NILES GROVE
FACILITY NUMBER: 019200191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
80061(b)

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80061(b) Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events... a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days.
This requirement is not met as evidenced by:
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Administrator agree to review section 80061(b)- Reporting Requirements and to submit to CCL a self-certification that the administrator understands the regulation and to have it signed by POC due date.
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Based on iinterviews, the licensee did not comply with the section cited above by not reporting an SIR to CCL with seven days after the event took place for C1 which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


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