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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200267
Report Date: 11/03/2021
Date Signed: 11/03/2021 03:40:00 PM

Document Has Been Signed on 11/03/2021 03:40 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:OAK HOME AT NILES GROVEFACILITY NUMBER:
019200267
ADMINISTRATOR:CLAY, CHANDREVEFACILITY TYPE:
735
ADDRESS:35543 NILES BLVD.TELEPHONE:
(510) 818-0650
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 5DATE:
11/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Edith Sarmiento, Back-up AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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On 11/3/2021 at 2:04PM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct case management for an incident report. LPA met with Back-up Administrator Edith Sarmiento and explained the purpose of visit.

Upon entry, LPA requested to take a look at the knives drawer in the kitchen. LPA observed the drawer was locked. Back-up Administrator took the magnetic key on the cabinet door where was right next to microwave, and open the knives drawer.

THE FOLLOWING DEFICIENCY WAS OBSERVED:
ยท At 2:10PM, LPA observed a magnetic key to unlock the knives drawer was unlocked, and easily accessible to clients in care. Back-up Administrator locked it up during visit.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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Document Has Been Signed on 11/03/2021 03:40 PM - It Cannot Be Edited


Created By: Catherine Lin On 11/03/2021 at 03:06 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: OAK HOME AT NILES GROVE
FACILITY NUMBER: 019200267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2021
Section Cited
CCR
80087(g)(1)

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80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items....
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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1. Back-up Administrator agrees to lock up the magnetic key at all time. Back-up Administrator locked it up during visit.
2. Back-up Administrator agrees to conduct an in-service training with staff, and provided a copy of the agenda with signatures to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above, LPA observed a magnetic key was unlocked, and easily accessible to clients which posed a potential health, safety or personal rights risk to persons in 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:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
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