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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200281
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:41:52 PM

Document Has Been Signed on 01/26/2024 02:41 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:DICHONDRA PLACEFACILITY NUMBER:
019200281
ADMINISTRATOR:LEEA BURNSFACILITY TYPE:
735
ADDRESS:5772 DICHONDRA PLACETELEPHONE:
(510) 894-1413
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 3CENSUS: 3DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Humfrey Kasweka/Leea BurnsTIME COMPLETED:
03:00 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
Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Karen Parramore. LPA explained to Parramore the purpose of the visit. Interim Administrator Humfrey Kasweka arrived at around 12:15 pm.

During the visit, LPA observed one client and 4 staff at the facility. LPA inspected the facility inside and out including but not limited to 3 client rooms and 2 bathrooms. There was sufficient supply of perishable and non perishable foods. LPA observed a fire extinguisher that appeared full and was last serviced on 7/12/2023. There are no bodies of water observed. Hot water in the kitchen and bathroom measured at 106 Fahrenheit.

At around 1:10pm, LPA reviewed 5 client files and 4 staff files. At 2pm, LPA interviewed 2 staff.

The following deficiencies were observed:
  • two bottles of Lysol cleaning chemicals were observed unlocked in the small bathroom at around 12:05pm
  • backyard fence was observed leaning towards the neighbor's side


Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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 3
Document Has Been Signed on 01/26/2024 02:41 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 01/26/2024 at 01:12 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: DICHONDRA PLACE
FACILITY NUMBER: 019200281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having backyard fence that leans toward the neighbor side which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
1
2
3
4
Administrator will get the fence fixed and submit photo proof to CCL by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/26/2024 02:41 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 01/26/2024 at 01:54 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: DICHONDRA PLACE
FACILITY NUMBER: 019200281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other 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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having two bottles of Lysol unlocked and accessible to clients in the small bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
1
2
3
4
Interim Administrator locked cleaning chemicals during the visit. This deficiency is cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3