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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201125
Report Date: 08/09/2023
Date Signed: 08/09/2023 04:10:03 PM

Document Has Been Signed on 08/09/2023 04:10 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:GLEN EDENFACILITY NUMBER:
019201125
ADMINISTRATOR:RAMAS, ELINOREFACILITY TYPE:
735
ADDRESS:238 ESTHER COURTTELEPHONE:
(510) 940-8382
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
08/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Maria Fatima Lacsamana, AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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On 8/9/2023 at 2:10PM, Licensing Program Analyst (LPA) G. Luk conducted a Case Management visit regarding an incident report received on 8/1/2023. LPA met with Administrator, Maria Fatima Lacsamana and explained the purpose of the visit.

Based on the incident report received on 8/1/2023, C1 left the facility without notifying staff on 7/28/2023. C1 did not returned to the facility after an hour and staff called 911 for assistance. After a few minutes, Hayward Police Department notified staff that C1 was found at the BART station and requested to be taken to John George.

At 3:00PM, LPA was informed that C1 does not have a physician's report and C1 was admitted to the facility in October 2022.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

LPA may return at a later time.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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 08/09/2023 04:10 PM - It Cannot Be Edited


Created By: Grace Luk On 08/09/2023 at 03:59 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: GLEN EDEN
FACILITY NUMBER: 019201125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2023
Section Cited
CCR
80069(b)

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Client Medical Assessment. In ARFs , prior to accepting a client...the licensee shall obtain...the client's medical assessment. This requirement is not met as evidence by:
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Administrator has agreed to obtain medical assessment and submit a copy to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by not having C1's medical assessment which poses a potential health and safety risk to the persons in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023


LIC809 (FAS) - (06/04)
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