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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201069
Report Date: 10/12/2021
Date Signed: 10/12/2021 06:03:19 PM

Document Has Been Signed on 10/12/2021 06:03 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:GENTLE HEART CARE SERVICES INCFACILITY NUMBER:
019201069
ADMINISTRATOR:SPENCER, ALANNAFACILITY TYPE:
735
ADDRESS:1559 D STREETTELEPHONE:
(510) 342-6740
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 3DATE:
10/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Alanna Spencer/AdministratorTIME COMPLETED:
06:10 PM
NARRATIVE
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While conducting investigation of a complaint (Control # 15-AS-20211008162448) and upon review of records and interviews, LPA learned that facility did not submit incident report to Community Care Licensing (CCL) when resident (R1) AWOL'ed.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Alanna Spencer.

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: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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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Document Has Been Signed on 10/12/2021 06:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/12/2021 at 05:31 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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2021
Section Cited
CCR
80061(b)(1)(E)

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80061Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events.. a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report...shall be submitted to the licensing agency within seven days
following the occurrence of such event
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Administrator to in-service staff and submit report as needed. Proof to be submitted by 10/26/2021.
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...(1) Events reported....:(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
-This requirement is not met as evidenced by:
-Based on interviews and records review, the licensee did not report to CCL when R1 AWOLed.
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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: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021


LIC809 (FAS) - (06/04)
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