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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200952
Report Date: 03/29/2024
Date Signed: 03/29/2024 11:27:42 AM

Document Has Been Signed on 03/29/2024 11:27 AM - 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:LINDA'S RESIDENTIAL CARE IIIFACILITY NUMBER:
079200952
ADMINISTRATOR:PORTILLO, ERLINDAFACILITY TYPE:
735
ADDRESS:5145 TURNBULL CTTELEPHONE:
(925) 565-5106
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
03/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Luis Fernandez, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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On 03/29/2024 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/28/2024. LPA met with Administrator (ADM) and explained the purpose of the visit.

The incident report received stated that on 02/26/24 at 9AM, Client (C1) was served a search warrant by police agents (PA) for alleged cybercrimes on the networks associated with pornography. The agents confiscated C1’s cellphone, tablet, and smartwatch. PA stayed with C1 in his room during visit and gave information on the case to staff (S1) for further investigation. On 02/28/24, staff held a meeting with C1’s Regional Center of the East Bay (RCEB) Quality Assurance Specialist (QA) and Case Manager (CM). One on one care and supervision on C1 by staff was implemented starting 8AM until 8PM daily. C1 agreed to non-use of smart devices to prevent reoccurrence of the incident. Staff continue to provide one on one care and supervision to C1 currently. During visit, ADM agreed to timely submit written notifications (LIC624) to CCLD within 24 hours of serious incidents and within 7 days following the occurrence of non-serious events.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. 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 appeal rights and this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2024
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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Document Has Been Signed on 03/29/2024 11:27 AM - It Cannot Be Edited


Created By: Daisy Panlilio On 03/29/2024 at 11:04 AM
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: LINDA'S RESIDENTIAL CARE III
FACILITY NUMBER: 079200952

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
80061(b)

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Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such an event.
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By POC due date, ADM agreed to conduct in-service staff retraining on reporting requirements which is to submit to CCLD timely written incident reports as required by TItle 22 Section 80061.
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This requirement was not met as evidenced by lack of the written unusual incident report (LIC624) submitted to CCLD of C1’s 02/26/24 event which poses a potential health & safety risk to clients 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:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024


LIC809 (FAS) - (06/04)
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