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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201440
Report Date: 08/21/2024
Date Signed: 08/21/2024 02:28:31 PM


Document Has Been Signed on 08/21/2024 02:28 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:JOY SENIOR CENTERFACILITY NUMBER:
079201440
ADMINISTRATOR:MATHARU, GURPREETFACILITY TYPE:
740
ADDRESS:6400 BRENTWOOD BLVDTELEPHONE:
(510) 543-4695
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:18CENSUS: 14DATE:
08/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Rose Constantino, CaregiverTIME COMPLETED:
01:24 PM
NARRATIVE
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On 08/21/2024 at 10:53AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 08/13/2024. LPA met with Rose Constantino, Caregiver and explained the purpose of the visit. Rose called Administrator, Gupreet Mathanu and LPA explained purpose of visit via telephone. Administrator gave the authorization for Rose Constantino to provide requested documents and sign the reports.

The regional office received an incident report stating R1 had wounds on the resident's buttocks S1 stated R1 moved into facility on 07/15/2024. S1 also stated R1 did not have an open wound but did have a scratch on buttocks. S1 noticed the scratch and observed R1 fingernails were long and she proceeded to cut them down , R1 informed S1 that he had been scratching his buttocks, possible resulting in the scratch on the buttocks.

LPA T. Syess-Gibson collected the following documents: Showering and Diaper changing schedule, After Visit summary(hospital) and staff schedule for the week of July 15,2024.

LPA observed the following Deficiency during visit:

LPA observed during interview that R1 has currently been admitted to the hospital for other health reasons since August 9, 2024 and it was not reported to CCLD

Exit interview conducted and a copy of this report and appeal rights was provided to Rose Constantino.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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 08/21/2024 02:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: JOY SENIOR CENTER
FACILITY NUMBER: 079201440

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.......
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Administrator has agreed to review reporting requirements and submit signed written statement of understanding to CCLD by POC date
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This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by not notifying CCLD of incidents within the seven days of occurance, and R1 being admitted to the hospital 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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