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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200363
Report Date: 03/24/2025
Date Signed: 03/24/2025 01:43:52 PM

Document Has Been Signed on 03/24/2025 01:43 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:HODGES CARE HOMEFACILITY NUMBER:
079200363
ADMINISTRATOR/
DIRECTOR:		WATSON, PARISFACILITY TYPE:
735
ADDRESS:2624 VIRGINIA AVENUETELEPHONE:
(510) 232-4046
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 6CENSUS: 4DATE:
03/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Mya Hodges, Care StaffTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 03/12/25 around 09:45 AM, Licensing Program Analyst (LPA) L. Holmes attempted visit.

On 03/24/2024 around 08:15 AM, LPA arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Care Staff, Mya Hodges and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of 6 (six) Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathroom, kitchen, common area, storage, front yard backyard. All outdoor and indoor passageways are kept free of obstruction. There were no bodies of water. A comfortable temperature for clients is maintained at 74 degree Fahrenheit. LPA observed lighting in all rooms to be adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 111.7. Toilets, hand washing and bathing areas were safe, sanitary and in operating condition. There were supplies of extra hygiene, paper products and emergency water available for staff and clients. There was a minimum one week supply of non-perishables and 2-day of perishables foods.

Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 11/24/25. Emergency Disaster Drill was last completed on 02/09/25. First aid kit was observed to complete.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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
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: HODGES CARE HOME
FACILITY NUMBER: 079200363
VISIT DATE: 03/24/2025
NARRATIVE
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...continued from LIC809.

LPA reviewed 4 client records, and 3 staff records.

At 11:13 AM, LPA observed recording errors on the MAR for R1, R2 and R3.

LIC500 Personnel Report (Reviewed)
LIC308 Designation of Administrative Responsibility (Reviewed)
LIC400 Affidavit Regarding Client/Resident Cash Resources (Reviewed)
Administrator Certificate (Reviewed)

Deficiency observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights, and a copy of this report provided to Care Staff, Mya Hodges.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2025 01:43 PM - It Cannot Be Edited


Created By: Lisha Holmes On 03/24/2025 at 11:59 AM
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: HODGES CARE HOME
FACILITY NUMBER: 079200363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80070
(b) Each record must contain information including, but not limited to, the following:

(10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and records reviewed, the licensee did not comply with the section cited above in 3 out of 4 client's MARs which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
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Licensee/ADM to review and correct MARs for R1, R2, and R3. Send proof of training and regulation review with signatures to CCLD by POC date.
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: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


LIC809 (FAS) - (06/04)
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