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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 05:17:26 PM

Document Has Been Signed on 11/15/2024 05:17 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Dillon Variz, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 11/15/2024 at 4:30 PM , Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 10/21/2024. LPA met with Program Manager, Dillon Variz and explained the purpose of the visit.

The incident report received stated that on 10/16/2024 Direct Support Staff (DSP), DSP1 was administering medication to Participant (P), P1 while they were out on a group outing. LPA interviewed Staff (S1) that confirmed that the incident report was correct. The incident report indicated that DSP1 administered and gave P1 two (2) out of the three (3) pills that they take while attending the program. The incident report further indicated that DSP1 turned away from P1 to write down the time that they were giving the medication to P1 and they looked in the pill bottle but did not see the pill. S1 stated that they were informed when DSP1 called them regarding the issue and that they went up to the location to look for the missing pill. S1 stated that they kept a watch on P1 to make sure that there wasn't any changes with P1 and that they informed the house manager where P1 lives that there was a missing dose of medication.

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.

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
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 05:17 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 11/15/2024 at 04:48 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Administrator agreed to conduct an In-Service Training with all DSP staff and submit sign-in sheet to CCLD by POC due date. In addition, add an addendum to their Plan of Operation how they will administer medications to participants while out in group outings and send the addendum to CCLD by POC due date.
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Based on LPA's interview licensee did not comply with the section cited above by not keeping record and knowing if the medication was swallowed by participant which poses an immediate health and safety risk to residents.
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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: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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