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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200773
Report Date: 09/24/2023
Date Signed: 09/24/2023 12:43:12 PM

Document Has Been Signed on 09/24/2023 12:43 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: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:
09/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Carol Dockery, CaregiverTIME COMPLETED:
12:55 PM
NARRATIVE
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On 9/24/2023 at 10:20am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Carol Dockery, Caregiver and explained the purpose of the visit. Administrator, Mya Hodges-Watson arrived at 10:20am. Administrator certificate #6011671735 expires 11/24/2023. Facility's fire clearance is for six (6) ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of three (3) total bedrooms and one and one-half (1 1/2) bathroom. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 81 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 134.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Emergency disaster plan updated 5/10/2020. Fire extinguisher was last services on 10/3/2022. Fire drill last conducted 7/19/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/24/2023
NARRATIVE
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LPA observed the following deficiencies:
  • At 10:25am, LPA observed S2 was not associated to the facility.
  • At 11:10am, LPA observed hot water temperatures at 134.5 degrees F.
  • At 11:35am, LPA observed during record review that clients cash safeguard is not accurate


LPA requested the following documents to be submitted to CCLD by 10/2/2023.
  • Client roster
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610D Emergency Disaster Plan (9 pages)
  • Liability Insurance


The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/24/2023 12:43 PM - It Cannot Be Edited


Created By: Laura Hall On 09/24/2023 at 12:15 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: HODGES CARE HOME #2
FACILITY NUMBER: 079200773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having the hot water temperature above 120 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2023
Plan of Correction
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Administrator agreed to adjust water to measure 105 - 120 and submit photo to CCLd by POC date.
Type A
Section Cited
CCR
80019(e)(2)
80019 Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

(2) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having S2 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2023
Plan of Correction
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Administrator associated S2 to the facility during visit. Deficiency cleared,
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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/24/2023 12:43 PM - It Cannot Be Edited


Created By: Laura Hall On 09/24/2023 at 12:20 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: HODGES CARE HOME #2
FACILITY NUMBER: 079200773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having cash safeguard accurate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
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Administrator agreed to update cash safeguard documents and submit copies to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2023


LIC809 (FAS) - (06/04)
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