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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200656
Report Date: 03/07/2024
Date Signed: 03/07/2024 05:12:39 PM

Document Has Been Signed on 03/07/2024 05:12 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:JAY MAHLER RECOVERY CENTERFACILITY NUMBER:
019200656
ADMINISTRATOR:GARCIA, DENISE GFACILITY TYPE:
772
ADDRESS:15430 FOOTHILL BOULEVARDTELEPHONE:
(510) 357-3562
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 16CENSUS: 11DATE:
03/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Clearnise Bullard/Administrator and
Michelle Mayberry-Porter/Regional Director 		TIME COMPLETED:
05:15 PM
NARRATIVE
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During the course of investigation of a complaint (Control # 15-AS-20240229112553), and upon review of incident reports submitted by the facility to the Department, Licensing Program Analyst (LPA) Delmundo learned that the facility did not submit Unusual Incident Report (UIR) for the incident that happened in February 2024 when resident (R1) was able to access the medication room which was unlocked at that time.

The above incident was discussed by LPA with Administrator Clearnise Bullard and Regional Director Michelle Mayberry-Porter.

Deficiency is cited from Title 22 Calofornia Code of Regulations and listed on 809D, Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed with the Administrator and Regional Director,

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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 03/07/2024 05:12 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/07/2024 at 04:26 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: JAY MAHLER RECOVERY CENTER
FACILITY NUMBER: 019200656

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2024
Section Cited
CCR
81061(b)(E)

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81061 Reporting Requirements
(b) ..., a written report.... shall be submitted to the licensing agency within seven days following the occurrence of such event.
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Administrator and/or Regional Director to do the following, and submit proof by 3/21/24:
1. Complete the incident report.
2. In-service the staff.
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-This requirement is not met as evidenced by:

-Based on interviews and records review, the licensee did not comply with the section above for not submiiting an incident report when R1 was able to access the medication room.
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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: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
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