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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600296
Report Date: 11/15/2024
Date Signed: 11/15/2024 05:11:35 PM

Document Has Been Signed on 11/15/2024 05:11 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:REHABILITATION & EMP. SVCS. OF THE EAST BAY, INC.FACILITY NUMBER:
075600296
ADMINISTRATOR/
DIRECTOR:		BREMNER, IANFACILITY TYPE:
775
ADDRESS:801 FERRY STREETTELEPHONE:
(925) 229-8228
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 30CENSUS: 20DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:24 PM
MET WITH:Dillion Variz, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 11/15/2024 at 12:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Program Manager, Dillon Variz and explained the purpose of the visit. Day program operates from 9:00 to 4:00 PM. There were eight (8) staff observed working with the 20 clients here today.

LPA toured facility with Dillon including but not limited to, multiple activity rooms, kitchen, bathrooms and office space. Clients bring their own lunches and snacks. Emergency supplies, including water were observed. The hot water temperature in the client bathroom measured 105 degrees Fahrenheit. Cleaning supplies are locked and inaccessible to clients. Medications were locked. There are no bodies of water or fire safety hazards observed. Restrooms are maintained in safe and in sanitary operating condition. Incontinent clients are kept clean and dry, and the facility is free of odors. The program has one (1) van used for client outings. Van maintenance logs were reviewed. Reviewed client and staff files for sampling. Emergency disaster drills was last conducted 11/08/2024. Fire extinguishers throughout facility were last inspected 10/23/2024. First aid kit was checked.

LIC809-C Continued....
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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Document Has Been Signed on 11/15/2024 05:11 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 11/15/2024 at 03:56 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: REHABILITATION & EMP. SVCS. OF THE EAST BAY, INC.
FACILITY NUMBER: 075600296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in by not having 8hrs training for Staff (S) S1, S5-S7 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator agreed to submit summary training transcripts for S1, S5-S7 to CCLD by POC due date.
Type B
Section Cited
CCR
82066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening, as specified in Section 82065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in by not having a copy of health screening on file for S6 which poses a potential health and safety risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Administrator agreed to submit a copy of health screening (LIC503) for S6 to CCLD by POC due date.
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:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2024 05:11 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 11/15/2024 at 03:56 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: REHABILITATION & EMP. SVCS. OF THE EAST BAY, INC.
FACILITY NUMBER: 075600296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in by not having a medical assessment on file with a negative TB result for Participant (P) P6 which poses a potential health and safety risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Administrator agreed to submit medical assessment and TB results for P6 to CCLD by POC due date.
Type B
Section Cited
CCR
82072(a)(3)
Personal Rights
(a) Each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication, or aids to physical functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in by not having Personal Rights (LIC613) for P2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Administrator agreed to submit copy of Personal Rights (LIC613) completed and signed by P2 and/or responsible party and submit to CCLD by POC due date.
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:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: REHABILITATION & EMP. SVCS. OF THE EAST BAY, INC.
FACILITY NUMBER: 075600296
VISIT DATE: 11/15/2024
NARRATIVE
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LIC809-C Continued...

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

The following forms to be updated and submitted to CCLD by 11/22/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Roster
LIC 610D Emergency Disaster Plan
Copy of Surety Bond

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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