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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441208
Report Date: 04/12/2024
Date Signed: 04/12/2024 01:03:22 PM

Document Has Been Signed on 04/12/2024 01:03 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:DYER FAMILY CARE HOMEFACILITY NUMBER:
071441208
ADMINISTRATOR/
DIRECTOR:		DYER, WANDAFACILITY TYPE:
735
ADDRESS:391 BECK STREETTELEPHONE:
(510) 232-7829
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 4CENSUS: 1DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Wanda Dyer, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 4/12/2024 at 10:45 am, Licensing Program Analysts (LPAs) L. Hall and L. Holmes conducted an unannounced continued annual required inspection. LPAs met with Wanda Dyer, Administrator, and explained the purpose of the visit. The facility’s fire clearance was approved for four (4) ambulatory clients. Facility has one (1) client.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) bedrooms and three and one-half (3 1/2) bathrooms. One (1) bedroom occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 120.3 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Continued on LIC9099C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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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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: DYER FAMILY CARE HOME
FACILITY NUMBER: 071441208
VISIT DATE: 04/12/2024
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Continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was serviced 12/8/2023. Emergency Disaster Plan was last posted on 1/6/2024. First aid kit was observed to be complete.

LPA reviewed two (2) staff records all were current and complete. Client file was current and complete. LPAs reviewed P & I.

The following forms to be updated and submitted to CCLD by 4/19/2024:
  • LIC500 Personnel Report
  • LIC400 Affidavit Regarding Client/Resident Cash Resources
  • LIC402 Surety Bond
  • LIC610D Emergency disaster plan (9 pages)


LPAs observed the following deficiency:
  • At 11:15am, LPAs observed during record review personal cash safeguards was not accurate.


Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2024 01:03 PM - It Cannot Be Edited


Created By: Laura Hall On 04/12/2024 at 12:45 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: DYER FAMILY CARE HOME
FACILITY NUMBER: 071441208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having accurate records for client's cash resources which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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Administrator agreed to obtain bank statement and correct cash safeguard ledger, and submit both to CCLD by PO date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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