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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200199
Report Date: 01/23/2025
Date Signed: 01/23/2025 11:42:36 AM

Document Has Been Signed on 01/23/2025 11:42 AM - 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:FCSN EAST BAY ADULT DAY PROGRAMFACILITY NUMBER:
019200199
ADMINISTRATOR/
DIRECTOR:		AI-CHING "SYLVIA" YEHFACILITY TYPE:
775
ADDRESS:2300 PERALTA BLVD.TELEPHONE:
(510) 739-6900
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 105CENSUS: 35DATE:
01/23/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Vivian Largusa, Program Director TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 01/23/2025, Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced case management visit regarding an incident report that was reported to CCLD on 01/17/2025. LPAs met with Program Director, Vivian Largusa, and explained the purpose of the visit.

The incident occurred on 01/16/2025, when client (C1) was given medication in error. Staff (S1) was interviewed and explained how the medication error occured. LPAs also interviewed the Program Director and Executive Director.

LPAs reviewed the Client's file, Client's Medication Log, Staff Files, Staff Training, Orientation Packet, Seizure Management.

The Program Director has implemented that medications will be passed out with a two person assist to confirm that the right medication is given, and observing the client while taking the medication. Then, the signature of the staff and client are required after the medication has been taken. The Program Director also implemented that each Medication bag will have a photo of the client in addition to having the name of the client.

Program Director has Medication Training to review medication procedures will be conducted on 01/29/2025. Program Director will send a copy to CCLD once training has completed.

LPAs will obtain the following documents such as Employee's Warning Letter, Updated Medication Administration Record (MAR), and updated Medication Training sent to CCLD by 01/30/2025.

A Technical Violation was issued today. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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