Community Care Licensing

Document Has Been Signed on 01/16/2025 05:03 PM - It Cannot Be Edited

FACILITY NAME:	DICHONDRA PLACE		FACILITY NUMBER:	019200281
ADMINISTRATOR/ DIRECTOR:	LEEA BURNS		FACILITY TYPE:	735
ADDRESS:	5772 DICHONDRA PLACE		TELEPHONE:	(510) 894-1413
CITY:	NEWARK	STATE: CA	ZIP CODE:	94560
CAPACITY: 3		CENSUS: 3	DATE:	01/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:10 PM
MET WITH:	Leea Burns, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:20 PM

SUPERVISORS NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025

Link to Parent Document Below:

FACILITY NAME: DICHONDRA PLACE	FACILITY NUMBER: 019200281
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2025

Type A

Section Cited

CCR

80087(g)

(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 Lysol bottle 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: 01/17/2025
	Plan of Correction
1 2 3 4	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

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025

Link to Parent Document Below:

FACILITY NAME: DICHONDRA PLACE	FACILITY NUMBER: 019200281
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2025

Type B

Section Cited

HSC

1565(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record, the licensee did not comply with the section cited above in having the last emergency drill conducted last August which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to conduct an Emergency Drill and send proof to CCLD.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025