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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201104
Report Date: 11/15/2022
Date Signed: 11/15/2022 11:43:58 AM

Document Has Been Signed on 11/15/2022 11:43 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:GOMES HOME ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
079201104
ADMINISTRATOR:GOOLSBY, DEONFACILITY TYPE:
735
ADDRESS:2717 GARVIN AVENUETELEPHONE:
(510) 233-5408
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 4CENSUS: 4DATE:
11/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Valencia Thomas,Direct Support ProviderTIME COMPLETED:
12:00 PM
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On 11/15/2022 at 11:00 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced visit to deliver the findings for of complaints 15-AS-20200626154213 and 15-AS-20200626135657 for a closed facility. LPA spoke with Administrator Marvin Tate prior to visit; he declined to meet and sign the report. LPA explained the purpose for the visit to Valencia Thomas, Direct Support Provider (DSP). Current Administrator Dejeon Gomes was telephoned, not able to meet at this time and DSP will sign the report.

During the course of the investigation and interviews, LPA requested the facility’s current LIC 500 and Client Roster. LPA asked which staff and clients transferred over from Facility #079200345 and LPA also requested the same documents for the time period 06/26/20 to 10/06/20. On 08/24/22, S1 replied by email that he/she would have to look through the files as S2 did not do a great job of keeping files. LPA requested the documents again on 09/09/22 and 09/13/22. The documents were not provided but were available for this visit.

Exit Interview conducted and a copy of this report provided to Valencia Thomas, Direct Support Provider.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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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