019200656-6-1-2023-15-AS-LHOS-CSE2NE-20230601173237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200656
Report Date: 06/01/2023
Date Signed: 06/01/2023 05:32:46 PM

Document Has Been Signed on 06/01/2023 05:32 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 CENTER		FACILITY NUMBER:	019200656
ADMINISTRATOR:	GARCIA, DENISE G		FACILITY TYPE:	772
ADDRESS:	15430 FOOTHILL BOULEVARD		TELEPHONE:	(510) 357-3562
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94578
CAPACITY:	16	CENSUS: 12	DATE:	06/01/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Denise Garcia, Administrator		TIME COMPLETED:	05:45 PM

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 06/01/23 around 03:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management for an Unusual Incident/Injury Report received 05/30/23 around 06:56 PM regarding Client #1 (C1). LPA met with Denise Garcia, Administrator (ADM) and explained the purpose of the visit. Samantha Nomura, Clinician will sign the report for ADM. LPA and ADM toured the facility. LPA interviewed ADM and Staff #1(S1). ADM explained that C1 had crossed several boundaries by winking and making kissing gestures to others in the facility since being admitted on 05/15/23 for a fourteen (14) day stay. There was a language barrier between Staff and C1, but Staff #2 (S2) was able to translate and had advised C1 that the behaviors were not acceptable. S1 explained that he/she had limited interaction with C1. C1 was assigned C2 as a roommate on 05/19/23. C1 told S1 that he/she was kept up all night because C2 humping his/her own bed. S1 assisted with moving C2 to another room. C1 gave S1 a thumbs-up. C1 asked S2 what was S1's name and title, and after that is when C1 approached S1's office on Saturday 05/20/23, at approximately 2:20 PM. C1 entered the S1's office and sat down in the chair. C1 asked S1 a unknown question and then moved closer to this S1. S1 left the room and C1 followed S1 into the hallway. C1 then grabbed S1's hand and attempted to pull S1 closer. With C1's left hand, C1 was making kissing gestures and motion toward his/her lips. ...continued on LIC809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CENTER	FACILITY NUMBER: 019200656
	VISIT DATE: 06/01/2023

NARRATIVE

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...continued from LIC809

S1 stated "No" and C1 continued to attempt to pull S1 closer. S1 called out to Staff #3 (S3), and C1 released the grip from S1 and walked away. S1 contacted ADM and was instructed to discharge C1 due to inappropriate physical contact with staff. S2 explained to C1 what actions were being taken. C1 gathered his/her belongings, medication and was escorted out of the facility by S3. C1 was provided a LYFT to the First Presbyterian Church Shelter in Hayward, CA.

For further review, LPA requested the following documents be submitted to CCLD by 06/06/23: LIC500, Client Roster, House Rules, Admission Agreement, Physician’s Reports, Appraisal/Needs and Services Plan, Medication Administration Records (MAR), Recovery Center Intake and Referral form, Hospital Discharge Summary, Client Episode and Closing sheet, Identification and Emergency Contact form, UIR's and Care Notes.

Exit interview conducted and a copy of this report was provided to Samantha Nomura.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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