<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200037
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:32:17 PM

Document Has Been Signed on 11/28/2023 03:32 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:RESIDENTIAL & EDUCATIONAL SERVICESFACILITY NUMBER:
079200037
ADMINISTRATOR:IAN BREMNERFACILITY TYPE:
775
ADDRESS:620 LAS JUNTASTELEPHONE:
(925) 957-1665
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 20CENSUS: 14DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shyrese Jenkins, Assistant ManagerTIME COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/28/2023 at 10:00AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Assistant Manager, Shyrese Jenkins and explained the purpose of the visit. Day program operates from 9:00am to 4:00pm. There were 6 staff observed working with the 14 clients here today.

LPA toured facility with Shyrese including but not limited to, multiple activity rooms, kitchen, bathrooms, office space, and the outside recreational area. Clients bring their own lunches and snacks. Emergency supplies, including water were observed. The hot water temperature in the client bathroom measured 105.8 degrees Fahrenheit. Cleaning supplies are locked and inaccessible to clients. Medications are not handled/dispensed by this program. There are no bodies of water or fire safety hazards observed. Restrooms are maintained in safe and in sanitary operating condition, and additional equipment for the physically handicapped was observed. Incontinent clients are kept clean and dry, and the facility is free of odors. The program has x vans used for client outings, and the 2 that were on the premises were observed to be clean. Van maintenance logs were reviewed. Reviewed client and staff files for sampling. Emergency disaster drills are conducted on a weekly basis at different times by each instructor. Fire extinguishers throughout facility were last inspected 08/01/2023. First aid kit was complete.


LIC 809-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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 4
Document Has Been Signed on 11/28/2023 03:32 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 11/28/2023 at 02:52 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: RESIDENTIAL & EDUCATIONAL SERVICES
FACILITY NUMBER: 079200037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(d)(1)
Needs and Services Plan
(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, record review, the licensee did not comply with the section cited above in by having current Appraisal Needs and Services or IPP for Participants #1-6 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2023
Plan of Correction
1
2
3
4
Licensee/Administrator will read the regulation and complete and submit Appraisal Needs and Services Plans or IPP for the participants. Will submit copies to CCLD by POC Due Date.
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by having a TB test for P3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2023
Plan of Correction
1
2
3
4
Licensee/Administrator will get TB test results for P3 and submit a copy to CCLD by POC Due Date.
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: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: RESIDENTIAL & EDUCATIONAL SERVICES
FACILITY NUMBER: 079200037
VISIT DATE: 11/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LIC 809 Continued...

The following forms to be updated and submitted to CCL by 12/05/2023:

LIC 500 Personnel
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
Surety Bond Insurance
Liability Insurance


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: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4