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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200774
Report Date: 12/12/2024
Date Signed: 12/12/2024 12:25:45 PM

Document Has Been Signed on 12/12/2024 12:25 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 #3FACILITY NUMBER:
079200774
ADMINISTRATOR/
DIRECTOR:		HODGES-WATSON, MYAFACILITY TYPE:
735
ADDRESS:2986 GILMATELEPHONE:
(510) 283-5309
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 4DATE:
12/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Mya Hodges-Watson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 12/12/2024 at 10:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 11/25/2024. LPA rang the doorbell and knocked on the door without a response. LPA spoke with Administrator, Mya Hodges-Watson over the phone and was informed that no one is currently at the facility. Administrator arrived 40 minutes later.

Incident report dated 11/25/2024 revealed that C1 shared an incident that happened last year (2023) with the behaviorist. The incident happened outside of the facility which involved C1 and C1's friend. Staff (S1) took C1 to Richmond Police Station to file a police report. C1 has 24 hours access to talk with counselor and crisis line.

During visit, LPA reviewed and obtained C1's IPP (Individual Program Plan), appraisal needs and service, emergency information, physician's report, and behavioral plan.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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