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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601514
Report Date:
01/10/2024
Date Signed:
01/10/2024 01:52:21 PM
Document Has Been Signed on
01/10/2024 01:52 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:
PENNY'S GUEST HOME
FACILITY NUMBER:
075601514
ADMINISTRATOR:
GARDNER, JOSEFINA
FACILITY TYPE:
740
ADDRESS:
78 RYEGATE PLACE
TELEPHONE:
(925) 361-8781
CITY:
SAN RAMON
STATE:
CA
ZIP CODE:
94583
CAPACITY:
6
CENSUS:
4
DATE:
01/10/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
11:20 AM
MET WITH:
administrator Josefina Gardner
TIME COMPLETED:
12:00 PM
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On 1/10/2024 at 11:20 AM (LPA) A. Gomez arrived unannounced to conduct a Case Management in regards to an incident report submitted to CCLD on 1/5/2024. LPA met with administrator Josefina Gardner and explained the purpose of the visit.
On 1/5/2024 CCLD received an incident report stating that R1 had passed away on 1/1/2024 in their sleep after being checked on by a caregiver arround 2:30AM. When caregiver retuned at 5:00AM resident was unresponsive. LPA obtained a copy of R1's death certificate that states that resident passed due to Emphysema. R1 also had other conditions such as hypertension and lung disease. LPA also obtained a copy of R1's physicians report.
No deficiencies cited during visit.
Exit interview conducted with Administrator and a copy of this report provided
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
01/10/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/10/2024
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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