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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201120
Report Date: 04/17/2023
Date Signed: 04/17/2023 11:40:39 AM

Document Has Been Signed on 04/17/2023 11:40 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:LEE FAMILY CARE HOME #5FACILITY NUMBER:
079201120
ADMINISTRATOR:TUCKER, WILLIAMFACILITY TYPE:
735
ADDRESS:186 PISTACHIO PLACETELEPHONE:
(925) 354-2254
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
04/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:William Tucker, Administrator and Maureen Lee, backup Administrator TIME COMPLETED:
11:55 AM
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On 04/17/2023 at around 10:00AM, Licensing Program Analyst (LPA) L. Ibo arrived at the facility unannounced to conduct case management related to self reported incident report received 04/10/2023. C1 left the facility unattended. LPA met staff on duty S1. LPA called Administrator William Tucker and backup Administrator Maureen Lee; LPA informed them the purpose of visit. At around 10:38AM Administrator William T. and backup Administration Maureen L. arrived at the facility.

Backup Administrator self- reported that on 4/10/2023 at around noon client (C1) AWOL’d through the front door. Staff looked around the facility and could not locate C1. Based on interview with staff, C1 was found after couple of minutes at the corner of the street, C1 was assessed and found no injuries noted.

Based on interview and records review C1 cannot leave the facility unassisted and is under staff one-on-one care.

Deficiencies are cited from Title 22 California Code of Regulations (see 809Ds). Failure to submit proof of corrections (POCs) by plan or correction due dates and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Administrator and backup Administrator.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
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 04/17/2023 11:40 AM - It Cannot Be Edited


Created By: Leslie Ibo On 04/17/2023 at 10:52 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: LEE FAMILY CARE HOME #5
FACILITY NUMBER: 079201120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2023
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.

-This requirement is not met as evidenced by:
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Administrator agreed to do the following and submit proof by 4/18/2023. In-service training for all staff regarding AWOL, self-certification document for all staff that will be attending the training.
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-Based on records review and interview, the licensee did not comply with Regulation, C1 AWOL’d from the facility and found at the corner of the street, no injury noted during the incident, which posed immediate health and safety to residents in care.
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Administrator will submit copy of training with attendees’ signatures by POC date.

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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023


LIC809 (FAS) - (06/04)
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