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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200878
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:05:49 PM


Document Has Been Signed on 04/28/2022 02:05 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: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: 6DATE:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Florentina Natnat, CaregiverTIME COMPLETED:
02:15 PM
NARRATIVE
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On 04/28/2022, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct case management and met with Florentina Natnat, Caregiver. LPA explained to Florentina Natnat the purpose of visit. Licensee John Williams arrived at 1:50pm.

On 4/4/2022, LPA Luisa Fontanilla received an exception request to allow facility to care for Resident 1 (R1). Upon verification with Administrator, it was found out that facility has admitted R1 on March 31, 2022 without an approved exception.

Deficiency is cited per Title 22 California Code of Regulations and listed on Lic 809D.

Exit interview was conducted with John Williams and Appeal Rights was provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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Document Has Been Signed on 04/28/2022 02:05 PM - It Cannot Be Edited

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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/29/2022
Section Cited

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(a) The use of alternate concepts, programs, services, procedures, techniques... personnel qualifications or staffing ratios...regulations provided that:
(2) A written request for a waiver or exception and substantiating evidence supporting the request shall be submitted in advance ,,,
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Based on information provided by Administrator, R1 was admitted to the facility on 3/31/2022. Facility sent CCL request for exception to care for R1 with colostomy bag on 4/4/2022 and is currently under review. The facility has admitted R1 to the facility without an approved exception which poses an immediate threat to the health and safety of R1.
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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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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