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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200734
Report Date: 12/09/2022
Date Signed: 12/09/2022 01:25:56 PM


Document Has Been Signed on 12/09/2022 01:25 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:JOY SENIOR CENTERFACILITY NUMBER:
019200734
ADMINISTRATOR:MATHARU, GURPREETFACILITY TYPE:
740
ADDRESS:6400 BRENTWOOD BLVDTELEPHONE:
(510) 543-4695
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:18CENSUS: 10DATE:
12/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Johana Calimlim, staff on duty TIME COMPLETED:
01:50 PM
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On 12/9/2022, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a Case Management regarding a report received from the facility alleging former staff (S2) married current resident (R1). LPA met with Caregivers S3 & S4. The staff called the Administrator and informed him the purpose of the visit. Administrator stated to provide copy of report to S3.

During the case management visit, LPA conducted staff interview and attempted to interview R1. LPA requested copy of R1’s file including but not limited to admission agreement, R1’s physician’s report, R1’s incident report for the last six months, R1’s financial documents document, six months facility’s residents outgoing and incoming log, three months staffing schedule and S2’s staff file; these documents needed to be submitted on or before 12/12/2022

Due to insufficient information at this time, LPA will conduct additional interviews and documents reviews. LPA will return to the facility.

Exit interview conducted with S3, copy of report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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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