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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201069
Report Date: 05/24/2024
Date Signed: 05/24/2024 05:52:56 PM

Document Has Been Signed on 05/24/2024 05:52 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/
DIRECTOR:
SPENCER, ALANNAFACILITY TYPE:
735
ADDRESS:1559 D STREETTELEPHONE:
(510) 397-4813
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 5DATE:
05/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Alanna Spencer/Administraror TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to Unusual Incident Reports (UIRs) for residents (R1, R2 and R3) submitted by the administrator. LPA met with Alanna Spencer, administrator, and informed the reason for visit. Administrator has to leave and authorized Elisa Chente to sign and receive this report.

UIRs indicated the following:
1. Resident (R1)
UIR dated 3/09/24 with incident date 3/08/24 - at 7:00 am, resident (R1) grabbed her backpack. Staff (S1) asked R1 where R1 is going, and R1 stated she's going for a walk. At approximately 12:00 p.m., staff (S2) called the Police Department and file a missing person report. R1 had missed medications during the time R1 AWOLed. On 3/11/24, S1 found R1 in the parking lot of a store. R1 was having behavior episode, crying and confused. After talking to Hayward Police, R1 was brought to John George.
2. Resident (R2)
UIR dated 2/05/24 with incident date 2/02/24 - at 2:00 p.m., staff (S3) found R2 doing drugs in R2's room. R2 was sweating profusely and eyes were bloodshot, and the room was filled with smoke. S3 confiscated the paraphernalia and opened the windows. Staff did room check every 20 to 30 minutes. A 30 day eviction was issued.
3. Resident (R3)
UIR dated 2/05/24 with incident date 2/04/24 - R3 admitted to doing drugs with R2.

On this day, LPA reviewed R1's LIC602 Physician's Report which showed R1 can leave the facility unassisted. LPA also interviewed the administrator. Administrator stated R2 went to rehab in March 2024 and will not come back to the facility. Administrator stated she didn't serve the eviction due to R2 volunteered to go to rehab. R3 at time of admitting to doing drugs with R2 was having unusual behavior and is now better.
No deficiency cited. Exit interview conducted, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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