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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200254
Report Date: 08/10/2023
Date Signed: 08/10/2023 05:28:12 PM

Document Has Been Signed on 08/10/2023 05:28 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:FAIRFIELDFACILITY NUMBER:
019200254
ADMINISTRATOR:LEEA BURNSFACILITY TYPE:
735
ADDRESS:32724 FAIRFIELD ST.TELEPHONE:
(510) 475-5383
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 4DATE:
08/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Leea Burns, AdministratorTIME COMPLETED:
05:45 PM
NARRATIVE
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On this day at around 3:30 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management - incident visit to follow up on Client 1 (C1). LPA was met by staff Omar Rivera. Lead staff Maria Teresa Bacaron arrived at a later time. Administrator arrived at around 4:30 pm.

On August 7, 2023, the Department received an incident report in regards to C1 falling in the bathroom on August 3, 2023. Facility reported that S3 notified Nurse Manage Ashton Paul prior to calling 911 despite seeing blood coming from C1's head. C1 was sent to the hospital. Discharge paper indicates C1 sustained laceration of scalp. Facility reported C1 sustained one stitch on the forehead.

At around 3:45 pm while at the facility, LPA observed C1's forehead and under right eye with bruises. LPA also observed a healing wound on C1's forehead. LPA interviewed Staff 1 (S1) and Staff 2 (S2) who both state that if a client falls, they call 911 immediately then notify Nurse Manager.

LPA obtained a copy of safety training that was conducted on 8/8/2023. However, facility does not have any safety training conducted prior to C1's fall on 8/3/2023.
***continuation on Lic 809C***
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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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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: FAIRFIELD
FACILITY NUMBER: 019200254
VISIT DATE: 08/10/2023
NARRATIVE
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Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Leea Burns and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2023 05:28 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/10/2023 at 04:59 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: FAIRFIELD
FACILITY NUMBER: 019200254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
80065(f)(3)

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80065 Personnel Requirements
(f) All personnel shall be given on-the-job training....
(3) Provision of client care and supervision, including communicationining or shall have related experience...
This requirement is not met as evidenced by:
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By POC date, Administrator will conduct inservice training and submit proof to CCL.
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Based on record review and interview conducted, facility failed to provide safety emergency protocol training to staff. On 8/3/2023, C1 fell in the bathroom. S3 responded and found C1 bleeding from the head. S3 informed Nurse Manager prior calling 911 which poses an immediate threat to safety of clients under 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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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