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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200578
Report Date: 11/16/2022
Date Signed: 11/16/2022 04:08:34 PM

Document Has Been Signed on 11/16/2022 04:08 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:CORDIAL CARE HOMEFACILITY NUMBER:
079200578
ADMINISTRATOR:OKEIGWE, OGEDIFACILITY TYPE:
740
ADDRESS:2957 HANNAN DRIVETELEPHONE:
(925) 947-5812
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 5DATE:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Winifred 'Willie' Wepee/Facility ManagerTIME COMPLETED:
04:15 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
During investigation of complaint (Complaint Control # 15-AS-20210629164337) and upon review of documents, the Department learned that upon admission of resident (R1), the facility did not conduct an intake evaluation and document any pre-existing marks or injuries on resident. Staff (S1) stated R1 had a bandage on backside when R1 arrived to the facility from the Emergency Department on 3/10/2021, but it was not documented anywhere. The facility keeps limited records and did not document a change in condition or keep progress notes on R1’s condition.

On this day, November 16, 2022, Licensing Program Analyst (LPA) Delmundo arrived to the facility unannounced and met with staff, Winifred 'Willie' Wepee, facility manager, and informed the reason for visit. LPA called and spoke with Ogedi Okeigwe, administrator, over the phone and informed of the above.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.



Deficiency and plan and proof of correction were discussed with the administrator over the phone in the presence of the facility manager.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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 2
Document Has Been Signed on 11/16/2022 04:08 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/16/2022 at 03:18 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: CORDIAL CARE HOME
FACILITY NUMBER: 079200578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2022
Section Cited
CCR
87466

1
2
3
4
5
6
7
87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning, and that appropriate assistance is provided when such observation reveals unmet needs. ..... the licensee shall ensure that such changes
1
2
3
4
5
6
7
R1 is no longer at the facility.
Administrator will come up wth a plan on how to properly observe and document changes in residents and communicate the changes to all the parties involved in residents' care needs.
8
9
10
11
12
13
14
are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
-This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section above for not properly observing and documenting resident's changes in condition.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2