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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201104
Report Date: 03/13/2023
Date Signed: 03/13/2023 12:54:07 PM

Document Has Been Signed on 03/13/2023 12:54 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:GOOLSBY, DEONFACILITY TYPE:
735
ADDRESS:2717 GARVIN AVENUETELEPHONE:
(510) 233-5408
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 4CENSUS: 3DATE:
03/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Valencia Thomas, Direct Support ProviderTIME COMPLETED:
01:15 PM
NARRATIVE
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On 03/13/23 Licensing Program Analyst (LPA) L. Holmes conducted an unannounced Case Management with Valencia Thomas, Direct Support Provider (DSP). The case management visit pertains to a Special Incident Report (SIR) dated 02/02/23. LPA spoke to Licensee Deon Goolsby by phone and advised her of the reason for the visit.

During the visit, LPA requested the LIC 500 and advised licensee that LPA did not receive criminal record clearance for Staff (S1 and S2). LPA verified that S1 and S2 were not associated in Guardian,

-On 02/05/23 at 02:50 PM, LPA L. Holmes received an email from S3 with an attached SIR for C1 along with photos of damaged property relating to an incident on 02/02/23. The description of the report identifies S1 and S2 as staff and present at the facility with C1.

- On 02/06/23 at 09:14 AM, LPA L. Holmes responded to the above email requesting a Client Roster, Staff Roster, and proof of criminal record clearance for S1 and S2.

- On 03/10/23 at 11:55 AM, S5 provided LPA with an LIC 500 dated 08/18/22. S1 and S2 are on the LIC 500 as Direct Support Staff. Licensee provided an additional email to record for future contact.

Civil Penalties are assessed of $1000.00
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Copy of report and appeal rights provided to Valencia Thomas, DSP
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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 2
Document Has Been Signed on 03/13/2023 12:54 PM - It Cannot Be Edited


Created By: Lisha Holmes On 03/13/2023 at 12:20 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: GOMES HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 079201104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2023
Section Cited
CCR
80019(e)(1)

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80019 Criminal Record Clearance (e) All individuals subject to a criminal record...shall prior to working, residing or volunteering: (1) Obtain a California clearance or a criminal record exemption...This requirement is not met as evidenced by:
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Licensee/Administrator will cease employment immediately for those that have not obtained criminal record clearance and ensure all staff are associated, provide a current LIC 500 to CCL and attest to reading regulation by 03/15/23.
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Based on observation and record review, the licensee did not comply with the section cited above by not obtaining criminal record clearance and associating S1 and S2 to the facility which poses an immediate health and safety or personal rights 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023


LIC809 (FAS) - (06/04)
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