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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200250
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:59:08 PM

Document Has Been Signed on 05/02/2024 02:59 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/
DIRECTOR:		MUNIZ, SHIELHA CFACILITY TYPE:
735
ADDRESS:2903 MCCLURE STREETTELEPHONE:
(510) 272-0104
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 25CENSUS: 23DATE:
05/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Nelson Luat, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On 5/2/2024, at 2:25pm Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 4/13/2024. LPA met with Caregiver, Nelson Luat and explained the purpose of the visit.

The incident report received stated that Client 1 (C1) left the facility on 4/12/2024, without saying anything to staff or signing out. Staff received called Oakland Police Department on 2/13/2024, and made a police report. On 2/13/2024, later in the morning staff was informed C1 had been arrested.

During today's visit LPAs were informed C1 had returned to the facility 5 - 7 days later. C1 left the facility again on 5/1/2024 with staff knowledge and has not returned. Staff made a police report again. LPAs reviewed C1's LIC602 (physician's report) which indicates C1 is able to leave the facility unassisted. S1 stated house rules indicate curfew is at 10:00pm, unless authorization is given for a later time. LPAs obtained C1's physician's report, admission agreement, and a copy of the house rules.

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: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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