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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200882
Report Date: 10/19/2023
Date Signed: 10/19/2023 02:15:15 PM


Document Has Been Signed on 10/19/2023 02:15 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CHERISH CARE HOME INC.FACILITY NUMBER:
079200882
ADMINISTRATOR:OKEIGWE, OGEDIFACILITY TYPE:
740
ADDRESS:15 DICKSON LANETELEPHONE:
(925) 250-3044
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 5DATE:
10/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Kimarley Whyte, CaregiverTIME COMPLETED:
02:30 PM
NARRATIVE
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On 10/19/2023 Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 10/06/2023. LPA L. Alexander met with Caregivers, Kimarley Whyte and Symone Reeves and explained the purpose of the visit.

LPA L. Alexander asked if the Resident #1 (R1) was still residing at the resident. Kimarley says that the resident moved out on 10/06/2023. Kimarley says that the resident went back to the hospital a second on 10/06/2023 and was discharged but they do not know where the resident went to next.

LPA L. Alexander received an e-mail and had a conversation with Licensee/Administrator, Ogedi Okeigwe, regarding the incident that 911 was called due to breathing issues that R1 was having and that he felt that R1 needs a higher level of care in which the caregiving staff is unable to give. Furthermore, the exception request for the PEG-Tube in which R1 had was also withdrawn.

LIC809C....Continued....
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 10/19/2023 02:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: CHERISH CARE HOME INC.
FACILITY NUMBER: 079200882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2023
Section Cited
CCR
87224(a)

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87224 Eviction Procedures
The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)
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Administrator/Licensee shall review the regulation and submit self-certification that they read and understand the regulation moving forward to CCLD by POC Due Date.

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Based on observation, review and interview the licensee did not comply with the section cited above by following appropriate eviction procedures o R1 which poses a potential health, safety and personal rights risk to persons in care.
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Type B
10/26/2023
Section Cited
CCR87637(a)

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87637 Health Condition Relocation Order
(a) If a resident has a health condition...Department shall order the licensee to relocate the resident.
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Administrator/Licensee shall review the regulation and submit self-certification that they read and understand the regulation moving forward to CCLD by POC Due Date.

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Based on observation, review and interview the licensee did not comply with the section cited above by assisting the relocation of R1 to another care facility which poses a potential health, safety and personal rights risk to persons 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CHERISH CARE HOME INC.
FACILITY NUMBER: 079200882
VISIT DATE: 10/19/2023
NARRATIVE
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LIC809....Continued

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3