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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 02:38:26 PM


Document Has Been Signed on 08/21/2024 02:38 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:
01:24 PM
MET WITH:Rose Constantino, CaregiverTIME COMPLETED:
02:40 PM
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On 08/21/2024 at 1:24PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 08/07/2024. LPA met with Rose Constantino, Caregiver and explained the purpose of the visit.

The regional office received an incident report stating R1 had an un-witnessed fall and was found by S1 in the bathroom on the floor, S1 says R1 expressed to staff that he fell down after using restroom and that he was okay at that time. S1 also states the next day R1 started complaining of pain, S1 called 911 and had the resident transmitted to Kaiser hospital for evaluation on 08/07/2024. R1 returned to the community later that night on 08/07/2024 with an After Visit Summary report indicating R1 had a fractured Rib. R1 can transfer and take care of all activities of daily living (ADL's) with assistance.

LPA spoke with R1 during visit. R1 stated he fell while in the restroom and landed between the toilet and shower and tried to get himself up from the floor he may have twisted his body wrong which may have cause the fracture to the rib. R1 used his call button for assistance once he realized he wasn't able to get up from the floor without assistance.

LPA T. Syess-Gibson collected the following documents: R1’s Physician's Report, After Visit Summary and Appraisal Needs and Service Plan .

No deficiencies issued during the visit and a copy of this report provided.

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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