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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600757
Report Date: 10/19/2023
Date Signed: 10/19/2023 06:30:24 PM


Document Has Been Signed on 10/19/2023 06:30 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: 41DATE:
10/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Juliana Taburaza/Licensee TIME COMPLETED:
05:15 PM
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While at licensee's other facility, Licensing Program Analyst (LPA) Delmundo conducted a case management for this facility, Family Courtyard, in response to the Unusual Incident Report (UIR) received by LPA on this day, October 19, 2023.

UIR indicated that resident (R1) who was recently admitted, left the facility on October 15, 2023 and didn't return. Staff called and filed missing person report to local law enforcement on October 16, 2023. R1's conservator was informed. As of the date UIR was submitted, R1 was still missing.

LPA interviewed licensee and requested for copy of LIC602A Physician's Report on this same day. LIC602A indicated R1 can leave the facility unassisted.

At 4:51 pm, licensee received information from Norma Tejero, administrator, which was forwarded to LPA. Administrator indicated R1 was found by local law enforcement and is currently at the hospital for stabilization.

No deficiency cited on this day.

Exit interview conducted and copy of this report provided to licensee.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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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