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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200977
Report Date: 10/09/2024
Date Signed: 10/09/2024 01:11:43 PM


Document Has Been Signed on 10/09/2024 01:11 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:WE CARE ELDERLY CAREFACILITY NUMBER:
079200977
ADMINISTRATOR:WHITE, BRITTANY DFACILITY TYPE:
740
ADDRESS:4155 BELL AVETELEPHONE:
(510) 375-4460
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:8CENSUS: 6DATE:
10/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Lurinza Bean, LicenseeTIME COMPLETED:
01:30 PM
NARRATIVE
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On 10/09/24 around 11:20 AM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding Unusual/Incident Reports (UIRs) for Residents (R1, R2) and a Death Report for R2. LPA met with Lurinza Bean, Licensee (S2) and explained the purpose of the visit.

On 10/01/24 ADM reported the following, “On 9/26/2024 R1 was having a virtual MD appointment, and We Care is requesting the primary care MD approve a request for a hospice evaluation due to recent decline. During appointment, the MD verbally instructed that Licensee, S2 to send R1 to ER for evaluation due to noted change in condition. 911 was alerted. Upon arrival to community, they successfully transported pt to ER for further medical evaluation. Pt conservator informed. Permission given for Hospice Evaluation Continue communicating to St. Mary's Hospital that pt needs a hospice evaluation.”

On 10/01/24 ADM reported the following, “On 9/26/2024 at approximately 12:30 PM R2 was observed in her bedroom unresponsive after x3 attempts of arousal by tapping shoulder and verbally calling out her name. Licensee, S2. 911 was alerted. Ambulance arrived and safely transported to Kaiser ER for further medical evaluation. Per ER, R2 will be admitted for further evaluation r/t Pneumonia. R2 remains admitted to hospital as of 10/1/2024. Continue to follow up with RP and Kaiser Hospital for patient’s current status.”


On 10/03/24, LPA received a DR for R2; date of death 10/02/24. On 10/04/24 LPA extended condolences to the family and facility, requested a death certificate, LIC602 and any other relevant care notes that happened within the months prior to R2’s death.

During the visit LPA reviewed the files for R1 and R2 including but no limited to R1's After visit summary for 09/2024 & 07/2024, R2's for 06/2024 & 09/2023 and Identification and Emergency Information for both.

Continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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 3


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: WE CARE ELDERLY CARE
FACILITY NUMBER: 079200977
VISIT DATE: 10/09/2024
NARRATIVE
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...continued from LIC809.

-At around 12:17 PM, LPA L. Holmes observed that R2 did not have an updated physician's report. The report in R2's file was dated 03/29/21.

Deficiency is cited on the attached LIC 809D. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided to Licensee, Lurinza Bean.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/09/2024 01:11 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: WE CARE ELDERLY CARE
FACILITY NUMBER: 079200977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
87458(c)

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87458 Medical Assessment (c) The licensee shall obtain an updated medical assessment when required by the Department. -This requirement is not met as evidenced by:
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Licensee to review the regulation, certify in-service training for all staff, and provide the latest LIC602 for R2 by POC date. Death Certificate to be provide to CCLD upon receipt.
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Licensee did not provide CCLD an updated medical assessment when requested on 10/04/24 and 10/09/24 for R2.
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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