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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201440
Report Date: 11/06/2024
Date Signed: 11/06/2024 03:25:46 PM

Document Has Been Signed on 11/06/2024 03:25 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/
DIRECTOR:		MATHARU, GURPREETFACILITY TYPE:
740
ADDRESS:6400 BRENTWOOD BLVDTELEPHONE:
(510) 543-4695
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 18CENSUS: 14DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:09 PM
MET WITH:Rose Constantino, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 11/06/2024 at 01:09PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 11/05/2024. LPA met with Rose Constantino, Caregiver, and explained the purpose of the visit.

The incident occurred on 11/01/2024 which involved a resident (R1) AWOL'd. LPA interviewed staff (S1) who was present during the time of incident. S1 stated on 11/01/2024 R1 ate lunch around 12:30pm and left the facility without staff being aware. At approximately 1:50PM a paramedic was at the door inquiring if the resident lives at the facility. S1 explained that R1 does live at the facility, and the paramedic stated they received a call from a witness who saw R1 fall near the corner.

S1 stated she went out the parking lot with the paramedic and observed R1 in the back of the ambulance on the gurney. While outside the paramedic called R1's daughter and explained the incident, R1 daughter arrived at the facility while paramedics examined R1. R1 stated she was okay and denied going to the doctor, R1 returned to the facility with daughter.

LPA obtained the following documents S1’s written statement, R1’s Physician Report (LIC602), R1’s Unusual Incident Reports, Staff Roster, Residents Roster during visit and Incident.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights was provided.

Continue on LIC809D

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 11/06/2024 03:25 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 11/06/2024 at 03:05 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: JOY SENIOR CENTER
FACILITY NUMBER: 079201440

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2024
Section Cited
CCR
87705(c)

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Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following.....
This requirement was not met as evidence by:
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Administrator agreed to implement a written plan that will show how the facility will prevent residents from AWOL. Plan will be submitted to CCLD by POC date.
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Based on interview and record review the Licensee did not comply with the section cited above in keeping residents from 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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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