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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200808
Report Date: 03/01/2024
Date Signed: 03/01/2024 02:02:19 PM

Document Has Been Signed on 03/01/2024 02:02 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:DOORSFACILITY NUMBER:
019200808
ADMINISTRATOR:ERIC UMALIFACILITY TYPE:
735
ADDRESS:1043 GILBERT STREETTELEPHONE:
(510) 363-8294
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 4CENSUS: 4DATE:
03/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Eric Umali/AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived to facility unannounced to conduct a case management inspection to follow-up on a self reported incident involving resident (R1). Report indicated that on February 17, 2024, at around 5:30 p.m., staff was done preparing dinner and R1 was about to wake up from supposed nap, staff found R1 missing. R1 exited from his room through the window with screen. The alarm was removed. Staff searched the nearby establishments, stores and bus stations immediately but unsuccessful. Staff called the Sheriff Department.

On this day, March 1, 2024, LPA met with Eric Umali, administrator, and informed the reason for visit.

LPA toured the facility with the administrator. LPA inspected the exit doors and windows which were observed with alarm/auditory signals. LPA conducted interviews. Review of documents revealed R1 has AWOL behavior, will walk away from the home and community and requires line of sight supervision. LIC602 Physician’s Report indicated R1 cannot leave the facility unassisted.

Administrator stated R1 was found by the police on February 24, 2024 drinking coffee at Starbucks in Daly City, and was brought back to the facility that day.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction along with the LIC9098 Proof of Correction form, and any repeat violations within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided,
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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 03/01/2024 02:02 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/01/2024 at 01:35 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: DOORS
FACILITY NUMBER: 019200808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2024
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

-This requirement is not met as evidenced by:
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Administrator stated resident will always be on line of sight of staff and provided 1:1 supervision.

In addition, administrator to do the following and submit proof by 3/02/24:
1. In-service the staff.
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-Based on records review and interview, the licensee failed to ensure R1 is provided the required supervision which resulted to R1 able to AWOL. This posed immediate health and safety risks to residentt in care.
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2. Update LIC625 Appraisal/Needs and Services Plan and ensure staff will be vigilant in providing supervision to the resident,

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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
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