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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601151
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:51:56 PM


Document Has Been Signed on 11/07/2023 02:51 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:AG HEALTH CARE, INC.FACILITY NUMBER:
075601151
ADMINISTRATOR:OSHINOWO, ANTHONYFACILITY TYPE:
740
ADDRESS:135 LOS CERROS AVENUETELEPHONE:
(925) 935-9626
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 4DATE:
11/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:ADMINISTRATOR ANTHONY OSHINOWOTIME COMPLETED:
03:00 PM
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On 11/07/2023 at 12:45 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for a Case Management visit regarding the Unusual Incident Report (UIR) dated 10/27/2023. The UIR concerned an allegation by Client 1 (C1) to Witness 1 (W1), who works at SVS CONCORD ADULT DAY PROGRAM License #079200383, where C1 is a client. The allegation was that C1 had been physically “attacked” by Staff 1 (S1) because C1 wanted to take medication at 6:00 PM rather than 7:00 PM as was ordered by S1’s physician on the evening of 10/26/2023.

The LPA interviewed C1 and the Administrator. The LPA found no evidence to support the allegation of abuse.

No citations issued during the visit.

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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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