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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600757
Report Date: 06/20/2022
Date Signed: 06/28/2022 12:02:40 PM


Document Has Been Signed on 06/28/2022 12:02 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:FAMILY COURTYARDFACILITY NUMBER:
075600757
ADMINISTRATOR:TEJERO, NORMAFACILITY TYPE:
740
ADDRESS:2840 SALESIAN AVENUETELEPHONE:
(510) 235-8284
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:70CENSUS: 48DATE:
06/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Medication/Floor Supervisor, Jiena GuienTIME COMPLETED:
02:45 PM
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On 06/20/2022 at 10:00 AM, Licensing Program Analyst (LPA) L Holmes arrived unannounced to conduct a Case Management visit in response to an Unusual Incident/ Injury Report (UIR) for Resident #1 (R1) submitted by the facility to Community Care Licensing Department (CCLD). After arrival at 10:05 AM, LPA saw two residents sitting in chairs outside at the front door and two residents seating inside at the entry of the facility. No staff was present when LPA arrived. LPA called the facility's telephone number and the Medication/Floor Supervisor, Jiena Guien arrived from the back of the facility stating that she was assisting a resident. LPA explained the purpose of the visit and asked if the Administrator (ADM), Norma Tejerao was present; ADM called in sick today, but Jiena said she'd be available to assist.

The UIR received 06/17/2022 indicated R1 AWOLed on June 13, 2022. On 06/12/2022, R1 was spotted with a wheelchair near the bus stop on Jiena's day off as he/she drove by San Pablo Ave. in Richmond, CA. R1 was instructed to return to the facility; he/she appeared to be sleeping, it was hot that day and he/she had on a long sleeved black jacket. Witness #1 (W1) stated that the paramedics were called by a bystander and the police were called by the facility. R1 was taken to John Muir Hospital in Concord, CA, discharged and returned to the facility on 06/13/2022.

LPA discussed the circumstances of the R1's history at the facility, AWOL, and behaviors including but not limited to self injurious actions with the ADM, S1, S2, and W1. LPA reviewed R1's Admission Agreement, House Rules, Identification and Emergency Information (LIC601), Consent for Emergency Care, Preplacement Appraisal Information (LIC603) dated 04/05/2021, Personal Rights (LIC613C) no date, Physician's Report 03/07/2022, Weight Record 05/20/2021 and Medication Administration Record (MAR) 06/2022. After interviews, R1 does leave the facility unassisted.

continued on 809C...
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: FAMILY COURTYARD
FACILITY NUMBER: 075600757
VISIT DATE: 06/20/2022
NARRATIVE
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...continued from 809

After reviewing R1's facility records, file and conducting interviews, LPA observed the following:
Physician's Report dated 03/07/2022 states mild cognitive impairment and no reappraisal has been completed. LIC601 is incomplete, unsigned and inaccurate. Personal Rights (LIC613C) is not dated, last Weight Record dated 05/20/2021 and has not been updated. LIC603 states dietary limitations include a mechanical soft diet; S1 and S2 are not aware and have not been given any dietary information or orders for R1; S1 and S2 only has dietary information for R2.

Deficiency is cited from Title 22 California Code of Regulations (see 809D).
Deficiency, plan and proof of corrections were discussed with Jiena.

Exit interview conducted, Appeal Rights, and a copy of this report provided to Medication/Floor Supervisor, Jiena Guien.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/28/2022 12:02 PM - It Cannot Be Edited

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: FAMILY COURTYARD
FACILITY NUMBER: 075600757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/06/2022
Section Cited

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87463 Reappraisals (a)The pre-admission appraisal shall be updated, in writing to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes physical, medical, mental, and social condition. -This requirement is not met as evidenced by:
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-Based on interviews and record reviews, the Administrator did not comply with the section above by not updating R1's Weight Records, LIC601, LIC603, LIC613C and Consent for Emergency Care which poses a potential health and safety risk to 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3