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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200807
Report Date: 09/16/2022
Date Signed: 09/16/2022 03:13:01 PM

Document Has Been Signed on 09/16/2022 03:13 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:CONTINUANCE CARE HOME LLCFACILITY NUMBER:
019200807
ADMINISTRATOR:MARSHALL, SHIRLEYFACILITY TYPE:
740
ADDRESS:565 SCHAFER RDTELEPHONE:
(510) 398-8994
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 16CENSUS: 15DATE:
09/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shirley Marshall, Administrator
Wyrek Fagin, Assistant		TIME COMPLETED:
03:25 PM
NARRATIVE
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On 9/16/2022 at 2:00PM, Licensing Program Analysts (LPAs) G. Luk and P. Watson arrived unannounced to conduct a Case Management visit. LPAs met with assistant, Wyrek Fagin. Administrator, Shirley Marshall was unable to stay to sign the reports.

While LPAs was at the facility for another visit, LPAs observed the following deficiencies:

- LPAs observed S1 was not fingerprint cleared or associated to the facility. LPAs check on Guardian and observed S1 was last associated to a different facility in 2016.

- LPAs observed back door had chain lock located near the top of the door and wooden rod put across the door that blocks the door handle.

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

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/16/2022 03:13 PM - It Cannot Be Edited


Created By: Grace Luk On 09/16/2022 at 02:27 PM
Link to Parent Document Below:
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: CONTINUANCE CARE HOME LLC
FACILITY NUMBER: 019200807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2022
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance. All individuals subject to a criminal record review...Obtain a California clearance or a criminal record exemption... This requirement is not met as evidence by:
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Administrator has agreed to obtain fingerprint clearance for S1 and have removed S1 off premises during inspection. Administrator will submit documents for S1's fingerprint to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by having staff that was not cleared working which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $500 is being assessed.
Type A
09/17/2022
Section Cited
CCR87468.1(a)(6)

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Personal Rights of Residents in All Facilities. To leave or depart the facility at any time and to not be locked into any room, building...
This requirement is not met as evidence by:
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Staff removed the chain lock and rod during inspection.


Deficiencies cleared.
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Based on observation, the licensee did not comply with the section cited above by having a chain lock and rod blocking the exit door which poses an immediate health and safety 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:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
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