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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200807
Report Date: 04/06/2023
Date Signed: 04/06/2023 12:00:02 PM


Document Has Been Signed on 04/06/2023 12:00 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: 14DATE:
04/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shirley Marshall, AdministratoriTIME COMPLETED:
12:00 PM
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On 4/6/2023 at approximately 9:30 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct Plan of Correction (POC) visit. LPA met with Shirley Marshall, Administrator and explained the purpose of visit. Administrator authorized staff Wyrek Fagin to sign the report on her behalf..

On 3/29/2023, a Type A citation CCR (c)(2) was issued to the facility regarding medications not being given to resident as ordered by physician. Plan of Correction (POC) is for facility to order medications missing from the list and submit proof to CCL by 3/30/2023.

Facility has not completed POC.

During the visit, Administrator contacted Resident 1 (R1) doctor and requested for a complete list of R1's medicines and called pharmacy. Administrator placed the order for 2 of R1's medications.

Civil penalty in the amount of $ 600.00 is assessed for the period 3/31/2023-4/5/2023. Facility is subject to ongoing penalties until deficiency is corrected.

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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