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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200603
Report Date: 09/04/2024
Date Signed: 09/04/2024 06:00:58 PM

Document Has Been Signed on 09/04/2024 06:00 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:OUR HOMEFACILITY NUMBER:
079200603
ADMINISTRATOR/
DIRECTOR:		DUGAN, BERNADETTEFACILITY TYPE:
735
ADDRESS:370 VERNAL DRIVETELEPHONE:
(925) 933-8706
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY: 6CENSUS: 2DATE:
09/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:15 PM
MET WITH:Licensee, Bernadette DuganTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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On 9/4/2024 Licensing Program Analysts(LPAs) A Gomez and P Manalo arrived unannounced to conduct a case management visit as a result of the department receiving notification that a client attempted suicide by ingesting over the counter medication. LPA's met with Licensee, Bernadette Dugan and explained the purpose of the visit.

On 8/20/2024 it was reported that C1 ingested approximately 12 over the counter acetaminophen in an attempt to commit suicide on the morning of 8/20/2024. Licensee notified LPA A Gomez via phone call on the day of the incident. LPA has not received the written report of incident but Licensee states that they emailed the report. Licensee states that they will resend the report. Licensee states that they were upstairs in the unlicensed part of the facility when the client "C1" came upstairs and informed the licensee that they had ingested medications. Licensee contacted the fire department and had the client transported to the hospital. Client was 5150 and has since returned to the facility. Licensee acknowledges that the clients were left unsupervised in the facility. Licensee states that the incident happened at approximately 9:30 AM.

****A Civil penalty is being issued in the amount of $250 for a repeat violation in 12 months****

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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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 09/04/2024 06:00 PM - It Cannot Be Edited


Created By: Alona Gomez On 09/04/2024 at 05:45 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: OUR HOME
FACILITY NUMBER: 079200603

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2024
Section Cited
CCR
80064(a)(2)

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(a)The administrator shall have the following qualifications:...(2) providing the type of care and supervision needed... with such clients.

This requirement was not met as evidence by:
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Mandatory meeting to be held at a later date.

A civil penalty was assesed
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Based on interview and observations the Licensee did not comply with the section cited above by not having adequate supervision for clients in care which posed an immediate safety risk to clients in care
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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:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024


LIC809 (FAS) - (06/04)
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