079201104-11-30-2021-15-AS-ADEO-C99SKJ-20211130125649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201104
Report Date: 11/30/2021
Date Signed: 11/30/2021 12:57:00 PM

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:	GOMES HOME ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	079201104
ADMINISTRATOR:	GOOLSBY, DEON		FACILITY TYPE:	735
ADDRESS:	2717 GARVIN AVENUE		TELEPHONE:	(510) 259-8337
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94804
CAPACITY:	4	CENSUS: 3	DATE:	11/30/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Dejon Gomes/Applicant and Deon Goolsby/Administrator		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this date, November 30, 2021, Licensing Program Analysts (LPAs) Alicia Delmundo and Lisha Holmes conducted an unaanounced pre-licensing inspection. LPAs met with Dejon Gomes (applicant) and Deon Goolsby (administrator). License application is for change in ownership for four (4) total capacity, all ambulatory. Fire clearance was approved on September 21, 2021. LPAs inspected the facility inside out including but not limited to living room, kitchen, dining and laundry areas, three bedrooms, bathrooms, front, back and side yards. No bodies of water observed. Physical plant lay out is consistent with the facility sketch received by Central Applications Bureau (CAB). LPAs observed adequate lighting. Bedrooms were properly equipped with furniture, lamps. night stands, drawers and beds with linens, covers, mattress pads and pillows. There were extra supply of linens and bed covers. Cabinet where medications were centrally stored was observed locked. Complaint poster was posted in a prominent place. LPA tested the facility land line telephone and observed operational. LPAs checked the personal protective equipments (PPEs). COVID-19 posters were observed posted all throughout the facility. Facility submitted the LIC808 Mitigation Plan to LPA Lisha Holmes. There's a central screening station by the entrance door. Fire extinguisher checked and tag showed serviced August 10, 2021. Facility has working carbon monoxide and smoke detectors Hot water temperature in one of the bathrooms was tested and measured at 118.7 degrees Fahrenheit. First aid kit was observed complete with manual. ....continued next page

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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: GOMES HOME ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 079201104
	VISIT DATE: 11/30/2021

NARRATIVE

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LPAs observed the following:
1. Stained carpet flooring in one of the residents' bedrooms.
2. Used mattresses on the side yard.
3. Paper towel in the bathrooms with no holders.
4. PPEs not sufficient for 30 days. There's only 60 N95 respirators and 80 disposable gowns for 5 staff.
5. Trash bin in the bathroom without lid.

LPAs discussed the requirement for N95 fit testing of staff.

Upon receipt of proof of corrections for the 5 items above and proof of N95 fit testing by December 14, 2021, LPA Lisha Holmes will inform CAB. Issuance of license is pending upon final review by CAB analyst.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC809 (FAS) - (06/04)

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