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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201104
Report Date: 10/15/2024
Date Signed: 10/15/2024 05:30:54 PM

Document Has Been Signed on 10/15/2024 05:30 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:GOMES HOME ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
079201104
ADMINISTRATOR/
DIRECTOR:		GOOLSBY, DEONFACILITY TYPE:
735
ADDRESS:2717 GARVIN AVENUETELEPHONE:
(510) 233-5408
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 4CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Valencia Thomas, Direct Support Provider TIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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On 10/15/24 Licensing Program Analyst (LPA) L. Holmes conducted an announced annual inspection with Valencia Thomas, Direct Support Provider (DSP). LPA spoke to Care Staff, Dejeon Gomes was telephoned by phone around 11:25 AM and advised him of the purpose for the visit; DSP arrived around 12:00 PM.

LPA and DSP toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All front passageways were free of obstruction; no bodies of water were present. There was a comfortable temperature for clients. LPA observed adequate lighting in all rooms for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom measured at 110.8 F. The shared bathrooms had soap and garbage cans. PPE, sanitizer, and paper goods remain sufficient. There was a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. Smoke detectors/carbon monoxide unit were in operating condition during visit. Fire extinguisher was last serviced on 07/24/2024. Emergency Disaster drill was last conducted on 07/2024. First aid kit observed complete.

The following forms are to be updated and submitted to CCLD 10/22/24:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate
-Resident Roster
-Liability Insurance

Continued on LIC809C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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 13
Document Has Been Signed on 10/15/2024 05:30 PM - It Cannot Be Edited


Created By: Lisha Holmes On 10/15/2024 at 04:39 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: GOMES HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 079201104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 1 of 4 staff files reveiwed, the licensee did not comply with the section cited above by not tranfering S1's background clearance in Guardian prior to wokring in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licencee to associate S1 in Guardian, read the regulation and self-certify completion by POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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2
3
4
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 10/15/2024 05:30 PM - It Cannot Be Edited


Created By: Lisha Holmes On 10/15/2024 at 04:39 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: GOMES HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 079201104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by allowing the lower kitchen cabinet door, the bathroom door in bedroom #2, and the hallway doors of the laundry area (3 of 3) to be either missing, off the henges and in disrepair. The ceiling vent in the hallway and the closet of bedroom #2 are filled with dust and need to be cleaned and sanitized. Two twin sized mattresses are along the walkway and against the backyard side fence.
The thermostat reader doesn't display the temperature. Cabinet/garbage area is unsanitary, and garbage can requires a lid all of which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licencee to provide photos too CCLD, read the regulation and self-certify completion by POC.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by 2 of 2 bathrooms having mildew present in the showers and tubs. Bathroom #1 paper towel holder is broken, and bathroom #2 toilet paper holder is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licencee to provide photos too CCLD, read the regulation and self-certify completion by POC.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


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: 10/15/2024
NARRATIVE
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...continued from LIC809.


LPA observed the following but not limited to the items noted below and on the LIC9102s:
1. Mildew in shower and tub of bathroom #1 and #2.
2. Used mattresses on the side yard.
3. Broken paper towel rack in the bathrooms #1; missing toilet paper rack in bathroom #2.
4. Broken bathroom door in bedroom #2, hallway doors and kitchen cabinet.
5. Trash bin in the kitchen without lid.
6. Dust in the hallway vent and bedroom #2.

Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided to DSP.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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