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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600757
Report Date: 10/16/2025
Date Signed: 10/16/2025 05:41:40 PM

Document Has Been Signed on 10/16/2025 05:41 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:FAMILY COURTYARDFACILITY NUMBER:
075600757
ADMINISTRATOR/
DIRECTOR:		TEJERO, NORMAFACILITY TYPE:
740
ADDRESS:2840 SALESIAN AVENUETELEPHONE:
(510) 235-8284
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 70CENSUS: 42DATE:
10/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Administrator Norma Tejero TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 10/16/2027 at 1015 AM, Licensing Program Analyst (LPA) David Doidge and Licensing Program Manager (LPM) J. Fong arrived unannounced to conduct a 1-Year Annual Required Inspection. LPA met with Administrator Norma Tejero and explained the purpose of the visit.

The LPA and LPM toured the facility inside and out with Licensee Joseph Taburaza. LPA and LPM inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and back yards. LPA and LPM observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. Hallway temperature was maintained at 61 degrees Fahrenheit. The hot water temperature was measured in multiple bathrooms between 116 and 116.7, and degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications are locked and inaccessible to residents in care.

The facility is an RCFE, however, it does not provide dementia care. 5 resident files were reviewed and had no information to indicate that sharp or other hazardous items would be danger to them.

Smoke detectors and carbon monoxide detectors were in operating condition. Fire extinguisher was last serviced on 07/18/2025. Emergency Disaster Plan was last posted on 10/18/2025. Emergency disaster and fire drills are conducted quarterly; last conducted on 05/07/2025. First aid kit was observed to be complete.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: David Doidge
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/16/2025 05:41 PM - It Cannot Be Edited


Created By: David Doidge On 10/16/2025 at 03:21 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: FAMILY COURTYARD
FACILITY NUMBER: 075600757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(b)(1)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
(b) A comfortable temperature for residents shall be maintained at all times.
(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having ambient air temperature in hallways measuring 61 degrees Fahrenheit and LPA and LPM observed that the physical plant was cold; LPM also observed 2 residents stating that they were cold; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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Licensee to monitor hallway air temperature, and keep it about 68 degrees Fahrenheit, take measurements and provide photos to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
David Doidge
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/16/2025 05:41 PM - It Cannot Be Edited


Created By: David Doidge On 10/16/2025 at 04:08 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: FAMILY COURTYARD
FACILITY NUMBER: 075600757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having window covers on Room 35 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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Licensee to install a window cover to provide privacy to resident in room 35 and provide photo proof to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
David Doidge
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2025 05:41 PM - It Cannot Be Edited


Created By: David Doidge On 10/16/2025 at 04:18 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: FAMILY COURTYARD
FACILITY NUMBER: 075600757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
87303(d) Maintenance and Operation.
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having adequate lighting throughout hallways. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2025
Plan of Correction
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License to install adequate lighting near bathrooms off hallways and ensure lights in hallways are kept on. Licensee provide photo proof to LPA by POC date. Licensee to have in-service training for staff and provide list of staff training to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
David Doidge
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FAMILY COURTYARD
FACILITY NUMBER: 075600757
VISIT DATE: 10/16/2025
NARRATIVE
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Continued from LIC809

The following deficiency were observed:

At 10:45 AM, LPA and LPM observed cold water faucet in bathroom by unoccupied room 20 does not run.

At 11:30 AM, LPA and LPM observed hallway air temperature measured at 61 degrees Fahrenheit, which felt cold. Two resident also expressed feeling cold while walking around hallways. LPA and LPM also observed inadequate lighting in hallways.

At 11:35 AM, LPA and LPM observed no window covering on window in room 35 allowing others to look in on the resident.

At 12:00 PM, LPA and LPM observed that the facility does not have an operating signal system. LPA and LPM overserved a pull call in residents’ bedroom, however they were nonfunctioning.
An immediate and repeat civil penalty of $250 is hereby assessed for inadequate lighting in hallways. This is the second time this regulation was cited in a 12 month period.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: David Doidge
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6