<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200395
Report Date: 10/20/2022
Date Signed: 10/20/2022 10:50:02 AM

Document Has Been Signed on 10/20/2022 10:50 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:PECO CARE HOMEFACILITY NUMBER:
019200395
ADMINISTRATOR:JEAN B. RODRIGUEZFACILITY TYPE:
735
ADDRESS:34914 PECO STREETTELEPHONE:
(510) 386-4912
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
10/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jean B Rodriguez, AdministratorTIME COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/20/2022 at 10:10AM Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct a case management visit to follow-up on a death report received by Community Care licensing. LPA met with Administrator, Jean Rodriguez and explained the purpose of the visit.

R1 passed away on 10/07/2022 with an unknown cause of death. During today's visit LPA obtained additional information pertaining to R1's death:

1. incident report dated 10/13/2022
2. death report
3. physician's report
4. needs and services plan/IPP

LPA requested from facility a copy of R1's death certificate.

LPA was informed by Administrator that family will provide R1's death certificate, once available and will provide CCL a copy.

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1