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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200281
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:56:54 PM

Document Has Been Signed on 08/15/2023 03:56 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:
08/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Leea BurnsTIME COMPLETED:
04:15 PM
NARRATIVE
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Ont his day at around 3pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit and met with Administrator Leea Burns. LPA explained to Burns the purpose of the visit. Nurse Manager Ashton Paul was also present at the facility during the visit.

Based on the incident report submitted to Community Care Licensing, Client 1 (C1) was in the backyard preparing for day program activities on 6/26/2023. As C1 was getting up, C1 lost balance and fell forward hitting front face on the pavement. Staff 1 (S1) observed blood coming from C1's nose. S1 called Nurse Manager and Lead Staff. C1 was transported to the hospital by staff.

A review of C1's discharge paper indicate " No maxillofacial fracture identified."

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

Exit interview with Administrator was conducted and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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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Document Has Been Signed on 08/15/2023 03:56 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/15/2023 at 03:33 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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
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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Administrator will conduct inservice training regarding the facility's fall protocol and submit proof of training to CCL by POC date.
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Based on record review conducted, facility failed to provide safety emergency protocol training to staff. On 6/26/2023, C1 fell in the backyard. S1 observed blood coming from C1's nose. S1 called Nurse Manager and Lead Staff. C1 was transported to the hospital by staff.
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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: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


LIC809 (FAS) - (06/04)
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