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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200882
Report Date: 11/16/2022
Date Signed: 11/16/2022 01:48:38 PM

Document Has Been Signed on 11/16/2022 01:48 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: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:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Kimarley Whyte/StaffTIME COMPLETED:
01:45 PM
NARRATIVE
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During investigation of complaint (Complaint Control # 15-AS-20210511161656) and upon checking of facility roster and the Department’s Guardian Portal for fingerprinted and associated individuals, the Department learned that staff (S1) was fingerprinted but not associated to this facility.

On this day, November 16, 2022, Licensing Program Analyst (LPA) Delmundo arrived to the facility unannounced and met with staff, Kimarley Whyte. LPA informed the purpose of visit. LPA called and spoke with Ogedi Okeigwe, administrator, over the phone and informed of the above.

Deficiency and plan and proof of correction were discussed with the administrator.

Exit interview conducted. Appeal Right, LIC9098 Proof of Correction form and copy of this report provided to Kimarley White.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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 11/16/2022 01:48 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/16/2022 at 01:20 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: CHERISH CARE HOME INC.
FACILITY NUMBER: 079200882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2022
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c).
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The staff no longer works in the facilty.
Administrator to read the Regulation and self-certify that in the future any individual prior to working will be associated. Self-certification to be submitted by 11/30/2022.
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-This requirement is not met as evidenced by:

-Based on interview and records review, the licensee did not comply with the section above for staff who is not associated to the facility which posed potential safety 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 Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


LIC809 (FAS) - (06/04)
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