075600757-12-16-2024-15-AS-LHOS-DBZRAV-20241216115146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600757
Report Date: 12/16/2024
Date Signed: 12/16/2024 11:52:01 AM

Document Has Been Signed on 12/16/2024 11:52 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:	FAMILY COURTYARD		FACILITY NUMBER:	075600757
ADMINISTRATOR/ DIRECTOR:	TEJERO, NORMA		FACILITY TYPE:	740
ADDRESS:	2840 SALESIAN AVENUE		TELEPHONE:	(510) 235-8284
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94804
CAPACITY: 70	TOTAL ENROLLED CHILDREN: 0	CENSUS: 47	DATE:	12/16/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Lenie Ibe, Staff		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 12/16/24 around 08:00 AM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to conduct a case management for an incident of alleged client abuse that was self-reported by the facility. The report was received by Community Care Licensing Department (CCLD) on 12/06/2024, dated 12/04/24. LPA met with Lenie Ibe, Staff and explained the purpose of the visit.

During the visit LPA interviewed Staff (S1, S2), Resident #1 (R1), and obtained a Resident Roster, Staff Roster, and requested the following for Resident #1 (R1): current Physician's Report, Appraisal and ID/Emergency Contact information. LPA requested the following for Staff #1 (S1): Training Records, disciplinary action, and photo identification. S1 resigned on 12/05/24. S1 was not at the facility during the time of the visit; however, S1's name remains on the Staff Roster and removal was requested. LPA confirmed with CCLD's Staff Support, A. Christy, that S1 is associated to multiple CCLD Adult and Senior Care facilities. Once all the information has been reviewed, CCLD will determine whether an immediate exclusion or non-immediate exclusion will be initiated.

-Around 10:10 AM, LPA reviewed S1's personnel records. S1's most recent training records were dated 05/08/22. S1 did not have any current training records on file.

Deficiency cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided to Lenie Ibe, Staff.

Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
Lisha Holmes	TELEPHONE: 510-286-4201
	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

Document Has Been Signed on 12/16/2024 11:52 AM - 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FAMILY COURTYARD	FACILITY NUMBER: 075600757
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of records (1) training and orientation shall be documented: (A) For staff who assist with personal activities of daily living …at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually …areas as specified in Section 87411(c)(2). - This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	Licensee agreed to provide in-service training to all staff and confirm that all staff’s training and records are updated. Submit a list of attendees’ signatures as proof to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
Lisha Holmes	TELEPHONE: 510-286-4201
	DATE: 12/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2