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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201181
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:09:22 PM

Document Has Been Signed on 08/08/2024 03:09 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:ADAURE HOME CAREFACILITY NUMBER:
079201181
ADMINISTRATOR/
DIRECTOR:		ESOMONU, JUSTINEFACILITY TYPE:
735
ADDRESS:1073 METTEN AVETELEPHONE:
(925) 635-3593
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 4DATE:
08/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Justine Esomonu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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On 8/8/2024 at 2:15pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 8/6/2024. LPA met with Justine Esomonu, Administrator, and explained the purpose of the visit.

The incident occurred on 8/4/2024 where C1 AWOL'd from the facility. S1 stated staff noticed C1 was missing at approximately 1:00am. S1 stated that C1 turned off the egress and exited the front door of the facility. At 3:30am, staff was notified by Sutter Delta in Antioch that C1 voluntarily checked himself in the emergency room and was discharged by to the facility.

LPA requested the following documents to be emailed to CCLD: physician's report, individual program plan (IPP), discharge summary, and dangerous propensities.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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 08/08/2024 03:09 PM - It Cannot Be Edited


Created By: Laura Hall On 08/08/2024 at 02:46 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: ADAURE HOME CARE
FACILITY NUMBER: 079201181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2024
Section Cited
CCR
80077.3(a)

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80077.3 (a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by... operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. ...devices must not substitute for staffing. This requirement was not met as evidence by:
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Administrator agreed to implement a plan to help deter client from AWOL'g and submit plan to CCLD by POC date.
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This requirement was not met as evidence by:
Based on interview the Licensee did not comply with the section cited above in having a plan for client not to AWOL, which poses a potential health and safety 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
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