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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200687
Report Date: 05/14/2021
Date Signed: 05/14/2021 01:09:29 PM

Document Has Been Signed on 05/14/2021 01:09 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:EDEN ASSISTED LIVINGFACILITY NUMBER:
019200687
ADMINISTRATOR:TET, SAMUELFACILITY TYPE:
740
ADDRESS:18787 CARLTON AVETELEPHONE:
(510) 885-0557
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 6CENSUS: 6DATE:
05/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Samuel TetTIME COMPLETED:
01:15 PM
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On 05/14/2021 Licensing Program Analyst (LPA) Allison O'Hollaren conducted an unannounced case management visit regarding a self-reported incident that occurred on 04/20/2021. Due to the Shelter in Place set forth by the Governor on March 17, 2020, LPA was not able to conduct the visit in person. The visit was performed by tele-visit. LPA spoke with Administrator, Samuel Tet.

During the visit LPA spoke and reviewed incident with Administrator. Administrator confirmed that R1 left the facility unsupervised. Administrator stated R1 may have left through an exit door in R1's bedroom. The exit door did not have a working alarm. After the incident, Administrator activated alarms to all exit doors. Administrator emailed R1's records per LPA's request.

The following deficiency was cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report emailed.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2021
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 05/14/2021 01:09 PM - It Cannot Be Edited


Created By: Allison O'Hollaren On 05/14/2021 at 09:10 AM
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: EDEN ASSISTED LIVING
FACILITY NUMBER: 019200687

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2021
Section Cited
CCR
87705(j)

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87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Deficiency cleared during visit. Administrator activated alarms to all emergency exit doors.
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Administrator confirmed that facility did not have working alarms on exit doors and R1 left the facility unsupervised which poses an immediate risk to health and safety of clients under 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2021


LIC809 (FAS) - (06/04)
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