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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200773
Report Date: 11/24/2021
Date Signed: 11/24/2021 12:32:35 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/15/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211115163341
FACILITY NAME:HODGES CARE HOME #2FACILITY NUMBER:
079200773
ADMINISTRATOR:HODGES-WATSON, MYAFACILITY TYPE:
735
ADDRESS:2988 GILMATELEPHONE:
(510) 283-5477
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 4DATE:
11/24/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Valrey Fails, staff
Mya Hodges, Administrator		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Administrator failed to inform staff and clients about a covid positive case at the facility
INVESTIGATION FINDINGS:
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On 11/24/21 at 11:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, gathered information and delivered the investigation finding. LPA explained the purpose of the visit with staff (S1) and administrator (ADM). LPA observed no clients present at the facility during visit. S1 stated that 1 client is out with family and the other 3 clients were at the day program.

ADM stated that staff (S2) went on vacation after 10/30/21 and reported to ADM that she tested COVID positive on 11/04/21 while on vacation. LPA observed ADM reported S2's COVID-19 positive case to Public Health and CCLD on 11/08-11/09/21. Per Public Health, facility does not qualify for outbreak due to the fact that S2 developed symptoms on 11/03/21 and last day of work was 10/30/21. ADM stated S2 has been on quarantine for 21 days and have not returned to work at the facility. Continued on next page, LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20211115163341
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 #2
FACILITY NUMBER: 079200773
VISIT DATE: 11/24/2021
NARRATIVE
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Per ADM, S2 has been fully vaccinated with J&J since 04/2021 and all clients have been fully vaccinated with booster shots. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited. Exit Interview conducted and a copy of this report provided to Administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2