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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200376
Report Date: 06/30/2023
Date Signed: 06/30/2023 05:29:10 PM

Document Has Been Signed on 06/30/2023 05:29 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: 30DATE:
06/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator NKEMDIRIM "Ken" UGBAJATIME COMPLETED:
05:30 PM
NARRATIVE
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On 06/30/2023 at 10:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct an Annual Inspection. Upon entry, LPA stated the purpose of the visit to staff. Administrator (ADM) Ken Ugbaja arrived at approximately 11:00 AM.

During inspection, LPA and ADM toured the facility. During the inspection, LPA reviewed files of 5 residents and 5 staff, and interviewed 3 clients and 3 staff members.

During the inspection, 3 Type-B citations were issued (refer to LIC809-D for details).

Exit interview conducted with ADM and a copy of this report was provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
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 06/30/2023 05:29 PM - It Cannot Be Edited


Created By: James Sampair On 06/30/2023 at 05:00 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: GREAT EXPECTATION RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 the kitchen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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On or before due date, conduct a deep clean of the kitchen and replace stove hood. Send picture proof to LPA on or before due date.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2023
Plan of Correction
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On or before due date, Licensee shall complete LIC610D. Send completed plan to LPA on or before due date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2023 05:29 PM - It Cannot Be Edited


Created By: James Sampair On 06/30/2023 at 05:00 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: GREAT EXPECTATION RESIDENTIAL CARE HOME
FACILITY NUMBER: 019200376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(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
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Based on record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2023
Plan of Correction
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On or before due date, Licensee shall complete this quarter's emergency disaster drill, schedule them for the future, and create a logbook of drills completed. Send proof to LPA on or before due date.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023


LIC809 (FAS) - (06/04)
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