<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200250
Report Date: 09/30/2022
Date Signed: 09/30/2022 01:54:41 PM

Document Has Been Signed on 09/30/2022 01:54 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MCCLURE CARE HOMEFACILITY NUMBER:
019200250
ADMINISTRATOR:MUNIZ, SHIELHA CFACILITY TYPE:
735
ADDRESS:2903 MCCLURE STREETTELEPHONE:
(510) 272-0104
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 25CENSUS: 23DATE:
09/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Marlene Lorincz, Care StaffTIME COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/30/22 at 10:10am, Licensing Program Analyst (LPA) C. Lin conducted a case management while conducting an complaint investigation visit. LPA met with staff and explained the purpose of the visit. Administrator Juliana Taburaza arrived at a later time.

Upon entry, LPA walked into the facility and observed no staff was on the first floor. Clients guided LPA to kitchen, LPA opened the kitchen door and observed no staff in the kitchen. Knives in the drawer were observed unlocked, a scissor on the sink was observed unlocked. 7 clients were observed either sitting in the dinning area, living room, or standing by the kitchen. 4 minutes later (at 10:14am), S1 walked down from upstairs, another minute later (at 10:15am), S2 also walked down from upstairs.

A deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty. A repeating civil penalty is assessed today.



Exit interview conducted with Administrator. LIC809D, appeal rights, and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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 2
Document Has Been Signed on 09/30/2022 01:54 PM - It Cannot Be Edited


Created By: Catherine Lin On 09/30/2022 at 10:56 AM
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: MCCLURE CARE HOME
FACILITY NUMBER: 019200250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2022
Section Cited
CCR
80087(g)

1
2
3
4
5
6
7
80087 Buildings and Grounds
(g)...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…
1
2
3
4
5
6
7
Administrator agrees to retrain staff for regulation and submit training agenda with staff signatures to CCL by POC due date.
8
9
10
11
12
13
14
Based on observation, records review, and interview, the licensee did not comply with the section cited above. LPA observed staff closed the kitchen door and left it unlocked, knives and scissors were accessible to clients where poses an potential health, safety or personal rights risk to persons in care.

8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2