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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200376
Report Date: 12/04/2023
Date Signed: 12/04/2023 01:41:27 PM

Document Has Been Signed on 12/04/2023 01:41 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:GREAT EXPECTATION RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200376
ADMINISTRATOR:NKEMDIRIM C. UGBAJAFACILITY TYPE:
735
ADDRESS:2301 98TH AVENUETELEPHONE:
(650) 303-1191
CITY:OAKLANDSTATE: CAZIP CODE:
94603
CAPACITY: 32CENSUS: 27DATE:
12/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH: Nkemidirim "Ken" Ugbaja, AdministratorTIME COMPLETED:
10:30 AM
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On 12/4/2023 at 9:45am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management visit to follow-up on a death report received by Community Care licensing on 6/25/2023. LPA met with Nkemidirim "Ken" Ugbaja, Administrator (ADM), and explained the purpose of the visit.

Client 1 (C1) passed away on 6/25/2023 with an unknown cause of death. ADM stated that after the visit of LPA L. Hall came for a visit a week after I found out from the hospital that the cause of death is heart attack.

No deficiencies cited during this visit.



Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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