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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200250
Report Date: 02/27/2024
Date Signed: 02/27/2024 01:10:49 PM

Document Has Been Signed on 02/27/2024 01:10 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: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: 20DATE:
02/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Nelson Luat, CaregiverTIME COMPLETED:
01:20 PM
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On 2/27/2024, at 12:30pm Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/16/2024. LPA met with Caregiver, Nelson Luat. LPA spoke with Administrator, Juliana Taburaza, via telephone and explained the purpose of the visit.

The incident report received stated that Client 1 (C1) gathered all belongings and left the facility on 2/15/2024, after receiving an eviction notice on 2/13/2024. Record review of C1's physician's report dated 3/29/2018, indicated that C1 is able to leave the facility unassisted. Staff 1 (S1) stated that C1 returned to the facility on 2/21/2024 and requested 9-1-1 to be called. S1 also stated that C1 was taken to Highland Hospital but was not admitted. At this time facility staff does not know of C1's whereabouts. LPA will return to facility if necessary.

No deficiency cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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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