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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200331
Report Date: 09/26/2024
Date Signed: 11/14/2024 08:59:16 AM

Document Has Been Signed on 11/14/2024 08:59 AM - 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:COVENTRY CARE HOMEFACILITY NUMBER:
019200331
ADMINISTRATOR/
DIRECTOR:		MARIDEL Q. CORTEZFACILITY TYPE:
735
ADDRESS:4284 COVENTRY WAYTELEPHONE:
(510) 972-0861
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 3DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Maridel CortezTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst Luisa Fontanilla arrived at the facility at around 9:45 am to conduct an annual required inspection. LPA met with Ricardo Cortez and Administrator Maridel Cortez.

The facility is a Level 3 home vendored by the Regional Center of the East Bay (RCEB) and has an approved fire clearance for six ambulatory clients. During the visit, LPA was informed by the Administrator that all clients are in their respective day program.

LPA inspected the facility inside and out including but not limited to client bedrooms, kitchen, dining area, bathrooms, backyard and garage. Hot water measured at 114. 4 Fahrenheit. There was sufficient supply of perishable and non perishable foods. There was ample supply of sheets, towels and warm blankets and hygiene products available for use of clients.

At 11:18 am, LPA reviewed 3 client files and 4 staff files. At 12 noon, LPA reviewed medications and Medications Administration Record (MAR) with the Administrator. At 12:15 pm, LPA reviewed P&I money and log. The facility has surety bond sufficient to cover amount of cash handled at one time.

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

Exit interview was conducted and Appeal Rights was provided.

***This is an amended copy of the report issued on 9/26/2024.***

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 11/14/2024 09:00 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/27/2024 08:55 AM


Created By: Luisa Fontanilla On 09/26/2024 at 12:33 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COVENTRY CARE HOME
FACILITY NUMBER: 019200331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

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
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Based on observation, the licensee did not comply with the section cited above in having unlocked chemicals in the 2 sheds in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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The Administrator locked the sheds during the visit. This deficiency is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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