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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200656
Report Date: 04/28/2022
Date Signed: 04/28/2022 04:01:19 PM

Document Has Been Signed on 04/28/2022 04:01 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: 13DATE:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Zohal Zamar, Nursing SupervisorTIME COMPLETED:
04:15 PM
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On 4/28/2022 at 2:30pm, Licensing Program Analyst (LPA) C. Fowler conducted an unannounced Case Management visit to follow-up an incidents report. LPA met with Nursing Supervisor Zohal Zamar. Administrator Denise Garcia also met with us via telephone.

At approximately 7:20pm staff heard the door chime sound and immediately conducted a head count and discovered C1 left the facility. After 20 minutes the facility contacted the local Sheriffs Department and filed a missing persons report, staff also contacted C1's conservator. Staff followed facilities appropriate procedures for AWOL clients. The facility is a voluntary recovery program and clients are free to leave the facility.

Based on physician's report dated 4/6/2022, R1 is not able to leave the facility unassisted. The nursing supervisor stated that the physician's report was incorrect and provided LPA with a corrected copy which states that the client is able to leave the facility unassisted.

No deficiency cited today.

Exit interview held with Zohal Zamar. A copy of this report was provided. .
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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