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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200734
Report Date: 05/31/2024
Date Signed: 05/31/2024 11:16:46 AM

Document Has Been Signed on 05/31/2024 11:16 AM - 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:JOY SENIOR CENTERFACILITY NUMBER:
019200734
ADMINISTRATOR/
DIRECTOR:		MATHARU, GURPREETFACILITY TYPE:
740
ADDRESS:6400 BRENTWOOD BLVDTELEPHONE:
(510) 543-4695
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 18CENSUS: 14DATE:
05/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH: Rose Constantino, Caregiver TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 5/31/2024 at 09:30AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and T. Syess- Gibson were at the facility for a Case Management LPAs observed that the back emergency exit pathway was blocked by two bedframes.

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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 05/31/2024 11:16 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 05/31/2024 at 10:34 AM
Link to Parent Document Below:
The Facility Number was changed to 079201440 After this Document was created!
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: JOY SENIOR CENTER
FACILITY NUMBER: 019200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2024
Section Cited
CCR
87307(d)(6)

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All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
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The facility agrees to remove the bedframes from the passageway. Proof of correction will be sent to CCLD by POC date.
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Based on observation the licensee did not comply with the section cited above by having bedframes blocking the emergency exit passageway from the back door which poses/posed a potential health, safety or personal rights risk to persons 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 Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
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