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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200616
Report Date: 12/08/2022
Date Signed: 12/08/2022 04:35:55 PM

Document Has Been Signed on 12/08/2022 04:35 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:LUCCHESI GROUP ADULT RESIDENTIAL CAREFACILITY NUMBER:
079200616
ADMINISTRATOR:VALADEZ, ARMANDOFACILITY TYPE:
735
ADDRESS:4739 LUCCHESI COURTTELEPHONE:
(925) 457-0913
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 4DATE:
12/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:25 AM
MET WITH:Armando Valadez, Administrator and Rafael Rubio , back-up Administrator TIME COMPLETED:
04:50 PM
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On 12/8/2022, Licensing Program Analyst (LPA) L. Ibo arrived to the facility unannounced to conduct case management related to incident report received 11/22/2022, C1 left the facility unattended. LPA met with Administrator Armando Valadez and backup Administrator Rafael Rubio, LPA informed her the purpose of visit.

Licensee self- reported that on 11/20/2022 at around 9:15AM client (C1) AWOL’d through the front door, at around 9:50AM staff called police to report missing client. Twenty minutes after staff reporting it to police, C1 was brought back to the facility by the authority. Based on interview C1 was found at the nearby store.

Based on interview and records review C1 cannot leave the facility unassisted. Facility started to have one on one care for C1. Staff assess C1, no injuries noted.

Deficiencies are cited from Title 22 California Code of Regulations (see 809Ds). Failure to submit proof of corrections (POCs) by plan or correction due dates and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Administrator and backup Administrator.

Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Exit interview conducted.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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 12/08/2022 04:35 PM - It Cannot Be Edited


Created By: Leslie Ibo On 12/08/2022 at 04:21 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: LUCCHESI GROUP ADULT RESIDENTIAL CARE
FACILITY NUMBER: 079200616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2022
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.

-This requirement is not met as evidenced by:
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Administrator agreed to do the following and submit proof by 12/9/2022.

In-service the staff and submit copy of training with attendees’ signatures.

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-Based on records review and interview, the licensee did not comply with Regulation, C1 AWOL’d from the facility and found at nearby store, which posed immediate health and safety to residents 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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