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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200388
Report Date: 10/16/2020
Date Signed: 10/16/2020 03:34:38 PM

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:BUTTONS ELDERLY CARE LLCFACILITY NUMBER:
079200388
ADMINISTRATOR:SHIRLEY VIRDENFACILITY TYPE:
740
ADDRESS:1448 BUTTONS COURTTELEPHONE:
(925) 354-9448
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 5DATE:
10/16/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Noah LakeTIME COMPLETED:
12:30 PM
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On 10/16/2020 at 11:30AM, Licensing Program Analyst (LPA) Leslie Ibo conducted a Case Management Tele-Visit to get additional information regarding Incident report that was received 10/15/2020. LPA spoke to staff Noah Lake, LPA informed Staff that the case management is being conducted via Facetime due to the shelter in place order and telework directive by management.

CCL office received incident report on 10/15/2020 stating that R1 was weak, did not take medication, with fever of 103F degrees and was sent to the hospital via 911. LPA interviewed Staff Noah Lake regarding R1 condition. Per Staff Noah Lake, R1 is back in the facility from John Muir Hospital on 12/13/2020, R1 was also tested negative from Covid19 before returning to the facility. Noah Lake informed LPA that the temperature that was listed on the incident report was an error and the real temperature was 100.3F.

LPA interviewed R1 to get more information regarding the incident on 10/12/2020, per R1 he is feeling a lot better. LPA L. Ibo advised Noah Lake to write down more information on Unusual incident reports in the future so that LPAs who reads the report will have more understanding on the incident.


There is no deficiency noted for this visit.

A copy of this report will be provided to Noah Lake via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2020
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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