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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200268
Report Date: 12/30/2024
Date Signed: 12/30/2024 12:56:13 PM

Document Has Been Signed on 12/30/2024 12:56 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:ASIAN FAMILY RESOURCE CENTERFACILITY NUMBER:
079200268
ADMINISTRATOR/
DIRECTOR:		MINDY LEEFACILITY TYPE:
775
ADDRESS:12240 SAN PABLO AVETELEPHONE:
(510) 970-9750
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY: 30CENSUS: 10DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Mindy Lee, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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12/30/2024 around 08:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection LPA met with Staff (S1) Mey Phan who contacted Mindy Lee, Program Director (PD) and advised about the purpose of the visit. PD arrived about 10 minutes later.

Upon entry, there we not any clients present. Around 09:15 AM, LPA observed one client enter the facility and greeted by staff. PD supplied a resident and staff roster, personnel records and client files. That facility serves full-time and part-time clients in person and via zoom. LPA observed the outside area and toured the facility inside, including but not limited to the program activity area, bathroom, kitchen. Facility was observed clean and odor free. Passageways and hallways were free of obstruction. The hot water measured at 114 degrees Fahrenheit (F). A sufficient supply of gowns, sanitizer, gloves, face shields, surgical masks, soap, paper supplies and N95's remain stocked. First aid kit was observed complete, fire extinguisher last serviced 10/18/2024, smoke detectors were observed operational, the room temperature was noted between 63-71 degree F to moderate temperature between the 1st and 2nd floors. The Day Program does not handle Personal and Incidental (P&I) money, medications or serve food to the clients.

Provide the following documents to CCLD by 01/06/2025:
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report (Updated during visit)
LIC 610 Emergency Disaster Plan (Reviewed)
Liability Insurance (Reviewed)

Continued on LIC809C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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Document Has Been Signed on 12/30/2024 12:56 PM - It Cannot Be Edited


Created By: Lisha Holmes On 12/30/2024 at 12:15 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: ASIAN FAMILY RESOURCE CENTER
FACILITY NUMBER: 079200268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience providing knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and records reviewed, the licensee did not comply with the section cited above by not identiying a Designated Adminstrative Responbile Party at all times which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2025
Plan of Correction
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Licensee to in-service staff of responsibilities when the Program Director and Licensee are unavailable, and to update the LIC 308.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
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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: ASIAN FAMILY RESOURCE CENTER
FACILITY NUMBER: 079200268
VISIT DATE: 12/30/2024
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...continued from LIC809.

LPA observed the following deficiencies:
-At 09:00 AM, LPA observed that S1 was not aware of the Staff or Resident Roster.
-At 09:10 AM, Licensee did not have any listed designated responsible parties available.
-At 11:10 AM, LIC 308 dated 07/01/2023 was not updated with a designated responsible party.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional penalties.

Exit interview conducted. A copy of this report and appeal rights provided to Mindy Lee, PD.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC809 (FAS) - (06/04)
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