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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200717
Report Date: 10/09/2020
Date Signed: 10/09/2020 03:19:03 PM

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:BAY HARBOUR CARE HOMEFACILITY NUMBER:
019200717
ADMINISTRATOR:RIVAS, DANIELAFACILITY TYPE:
740
ADDRESS:510 CENTRAL AVETELEPHONE:
(510) 523-0113
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:12CENSUS: 3DATE:
10/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Daniela Rivas, Administrator
Bernadette Hunsaker, Resident Care Coordinator		TIME COMPLETED:
03:15 PM
NARRATIVE
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On 10/9/2020 at 2:50PM, Licensing Program Analyst (LPA) G. Luk conducted a Case Management Tele-Visit via FaceTime due to shelter in place order directed by the Governor. LPA spoke to Administrator, Daniela Rivas and Resident Care Coordinator, Bernadette Hunsaker.

During investigation of complaint 15-AS-20190905162901, it was revealed that facility did not report to CCLD when a resident had an unwitnessed fall and sustained injury.


The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020
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: BAY HARBOUR CARE HOME
FACILITY NUMBER: 019200717
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/23/2020
Section Cited

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Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days...Any incident which threatens the welfare, safety or health of any resident... This requirement is not
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met as evidence by: Based on investigation, licensee did not comply with reporting requirements which poses a potential health and safety risk to the residents 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2020
LIC809 (FAS) - (06/04)
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