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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200878
Report Date: 06/14/2021
Date Signed: 06/15/2021 10:44:57 AM

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:WILLIAMS FAMILY CARE HOMEFACILITY NUMBER:
019200878
ADMINISTRATOR:WILLIAMS, GLADYS GFACILITY TYPE:
740
ADDRESS:674 GLENEAGLE AVENUETELEPHONE:
(510) 441-1180
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: 5DATE:
06/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gladys Williams/John Williams/Bianca AsiTIME COMPLETED:
03:15 PM
NARRATIVE
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On this day, Licensing Program Analysts (LPAs) Luisa Fontanilla and Carol Fowler conducted a Zoom televisit and met with Administrators Gladys & John Williams and Bianca Asi. LPAs explained to the Administrators the purpose of the televisit.

This televisit is conducted in connection with a fall incident reported to this office. Resident 1 (R1) Physician's Report, Needs and Services Plan and Lic 500 were requested and reviewed. LPAs interviewed Administrators and Staff 1 (S1). LPAs also tried to interview R1. However, LPAs observed R1 is not capable of communicating due to Dementia.

Based on interviews and records reviewed, R1 has dementia and is not allowed to leave facility unassisted.
On May 9, 2021, R1 was found outside the facility in front of next door neighbor's house. Administrator John Williams called 911 and R1 was sent out to the hospital. On 5/21/2021, R1 was admitted to a skilled nursing facility for rehabilitation with a diagnosis of Fracture of unspecified part of neck of right and left femur, subsequent encounter for closed fracture with routine healing and unspecified fracture of right patella..

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC 809D. A $500.00 immediate civil penalty is assessed on this day and will continue for $100.00 per day until corrected.


Exit interview was conducted. Appeal Rights, LIC421IM and a copy of this report was sent via email..
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WILLIAMS FAMILY CARE HOME
FACILITY NUMBER: 019200878
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2021
Section Cited

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87411 Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
Based on interviews and records review,
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R1's physician's report indicates R1 has dementia and is not able to leave facility unassisted. On May 9, 2021, R1 was able to leave facility unassisted, fell and was hospitalized with fracture of unspecified part of neck of right & left femur...unspecified fracture of right patella...which poses an immediate threat to safety of clients under care.
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Civil penalty of $500 is assessed for less serious injury.

Civil penalty determination related to serious bodily injury is pending.

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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2021
LIC809 (FAS) - (06/04)
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