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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200446
Report Date: 11/02/2021
Date Signed: 11/02/2021 06:16:08 PM

Document Has Been Signed on 11/02/2021 06:16 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:BRIDGESFACILITY NUMBER:
019200446
ADMINISTRATOR:SOKODOLO, KOLU G.FACILITY TYPE:
735
ADDRESS:21259 BIRCH ROADTELEPHONE:
(510) 244-7153
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 4CENSUS: 4DATE:
11/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Joselito Sarmiento/Lead StaffTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Unusual Incident/Injury Report (UIR) submitted by Regional Director Lorenzo Pennix to the Department. LPA met with Lord 'Wilson' Carillo, staff. Kolu Sokodolo, administrator, is not available so LPA called and spoke with Lorenzo Pennix. LPA later met with Joselito Sarmiento, lead staff LPA informed them the purpose of visit. Lorenzo Pennix authorized Joselito Sarmiento to sign and receive this report.

UIR indicated that the incident took place on October 17, 2021. Staff (S2) observed staff (S1) slapping client (C1) and had a video of the incident. S1 waited until S1 could meet Kolu Sokodolo on Saturday, October 23, 2021. S1 was removed from schedule on October 24, 2021.

On this day, November 2, 2021, LPA conducted interviews. LPA also received on this same day copies of S1 and S2's LIC501 Personnel Record.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof correction by plan of correction due date may result in civil penalty,

Deficiency and plan and proof of correction were discussed with Lorenzo Pennix over the phone.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Joselito Sarmiento.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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 11/02/2021 06:16 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/02/2021 at 05:46 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: BRIDGES
FACILITY NUMBER: 019200446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2021
Section Cited
CCR
80072(a)(1)

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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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S1 no longer works in the facility.

Regional Director to conduct in-service training and submit proof by 11/03/2021,
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-Based on records review and interview, the licensee did not comply with the section above. S1 slapped C1 which posed immediate personal rights risk to person in care.
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021


LIC809 (FAS) - (06/04)
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