Other·February 28, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of complaint: CA00615215. Representing the Department of Public Health : Health Facilities Evaluator Nurse, 38416 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. An Immediate Jeopardy (IJ) situation was called on 12/11/18 at 4: 27 p.m., with the facility Administrator (Admin 1), Assistant Administrator (Admin 2), and the Director of Nursing present during the notification. The facility had knowledge of the inappropriate sexual behavior of Resident 2 and failed to provide Resident 1 with adequate safety and put in place preventative measures to protect her from being sexually assaulted a second time by Resident 2. The IJ was abated on 12/11/18 at 6:54 p.m. after receiving a plan of correction indicating Resident 2 would be placed on one to one supervision to protect Resident 1 and other females in the facility from Resident 2's sexually assaultive behavior.

F600 SS=J Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 02/11/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1G5F11 Facility ID: CA020000125 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A396 (X3) DATE SURVEY COMPLETED 02/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to prevent one of three sampled residents from being sexually assaulted by a male peer (Resident 2). This failure resulted in Resident 1 being sexually assaulted twice by Resident 2 and left her at risk for continued assault. An Immediate Jeopardy (IJ) situation was called on 12/11/18 at 4: 27 p.m., with the facility Administrator (Admin 1), Assistant Administrator (Admin 2), and the Director of Nursing present during the notification. The facility had knowledge of the inappropriate sexual behavior of Resident 2 and failed to provide Resident 1 with adequate safety and put in place preventative measures to protect her from being sexually assaulted a second time by Resident 2. The IJ was abated on 12/11/18 at 6:54 p.m. after receiving a plan of correction indicating Resident 2 would be placed on one to one supervision to protect Resident 1 and other females in the facility from Resident 2's sexually assaultive behavior. Findings: Review of the Minimum Data Set (MDS-an assessment tool used to direct health care needs) on 12/11/18 showed Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1G5F11 Facility ID: CA020000125 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A396 (X3) DATE SURVEY COMPLETED 02/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE admitted to the facility on 7/19/17 with multiple diagnoses including Non-Alzheimer's Dementia (memory loss). Resident 1 was dependent on staff for all of her daily care needs, was nonverbal, and required one person to assist her with mobility on the unit. Review of the MDS dated 9/13/18 showed Resident 2 was admitted to the facility on 1/20/16 with multiple diagnoses which included Insomnia (inability to sleep at night). Resident 2 was independent with his daily care needs and his ability to move around the unit. Observation of Resident 1's room on 12/11/18 at 2:25 p.m., showed Resident 1's room was not visible from the Nursing Station and was located toward the back of the building. Review of Resident 2's "Care Plan" revised 11/19/18, showed Resident 2 had displayed sexually aberrant (abnormal) behavior by attempting to grab other residents' and staffs' genitalia. The care plan also showed on 11/18/18, that Resident 2 laid on top of Resident 1 and as a result, Resident 2 would be placed on "indefinite close monitoring due to his wandering into other rooms". Review of Resident 1's Care Plan dated 11/18/18 showed Resident 1 was, "found with male peer (Resident 2) on top of her with his pants and underwear down; Resident 1's brief was open, but no sexual contact yet, staff separated them right away." This care plan showed that some interventions were to inform the physician and responsible party for unusual changes and monitor Resident 1 for emotional distress and safety every 15 minutes. Review of Resident 1's "Care Plan" dated 12/8/18 showed, "On December 8, 2018, a male peer (Resident 2) on top of Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1G5F11 Facility ID: CA020000125 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A396 (X3) DATE SURVEY COMPLETED 02/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with his pants down and staff (Hskp 1) intervened and stopped male peer (Resident 2) right away". The interventions for the 12/8/18 care plan were to monitor Resident 1 every 15 minutes for safety and a sign was placed on Resident 1's door that read "Females Only". The added intervention for the second sexual assault was the sign placed on Resident 1's door. Review of the facility's "Every 15 minute-24 hour Precautionary Checklist/Contact Log" dated 12/8/18 showed, there was no observations made of Resident 1 on the unit or of her in her room (by staff indication of initials) from 11:15 p.m. to 12:45 a.m. Review of the facility's "Every 15 minute - 24 hour Precautionary Checklist/Contact Log" dated 12/8/18 showed, there were no observations made of Resident 2 on the unit or of him in his room (by staff indication of initials) 11:15 p.m. to 12:45 a.m.. During an interview with CNA 1 on 12/21/18 at 2:22 p.m., CNA 1 stated, "I was doing the rounds from 12 a.m. to 1 a.m.. Resident 2 was given a sandwich around 12:45 a.m.. I went to the Chart Room to fill out the rounds book and about five to ten minutes later I heard the laundry lady calling for help. We went out, the RN 1, myself, and CNA 2; Resident 2 was already off of Resident 1's bed, coming out of the room. Resident 1's gown was up and her brief was off on one side. Resident 1 was awake; she didn't say anything; she didn't respond. We then changed Resident 1's brief and put another gown on her." During an interview on 1/4/19 at 10:33 a.m., Housekeeper (Hskp 1) stated, "It was around 12:58 a.m., and I was working the night shift and I was exiting the elevator that is next to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1G5F11 Facility ID: CA020000125 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A396 (X3) DATE SURVEY COMPLETED 02/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1's room. As I was passing Resident 1's room, I saw Resident 2 on top of her. Resident 1's gown was open, you could see her breasts and stomach, and the brief was unfastened on one side. Resident 2 was on his knees with pants down and he was on top of Resident 1 and he was holding his shirt up; Resident 2 did not have a gown on. I saw his butt and his private and I don't think he had the chance to do much more because the brief was still partially on. I yelled, 'Stop! Get off of her!' There should have been somebody at the desk (Nurse Station 2) at all times, but no one was there. I kept yelling for staff to come and help and no one came. Resident 2 then got off of Resident 1 and came at me. I put my work cart between us; and finally the Charge Nurse (RN 1) came out and Resident 2's attention went towards her. Resident 1 was yelling in her own way. We tried to figure out what her needs were. I don't think she wanted Resident 2 in her room or on top of her. Resident 1 was not capable of communicating and I heard this was not the first time". During an interview with RN 1 on 12/21/18 at 2:45 p.m., Registered Nurse (RN 1) stated, "Resident 2 had been bothering staff for a snack. One staff had already given him a snack then I gave him a snack. CNA 2 was making rounds and CNA 2 also gave him a snack. It is 12 a.m. or 1 a.m., this was at nightearly morning. I stayed at Station 2 and saw Resident 2 eating there at the station. I went to check on him four to five minutes later and he was gone. Then two or three minutes later I heard staff screaming, 'Hey, hey, hey'. I went to check why the screaming and who was screaming and I saw Resident 2 trying to hit Hskp 1, who was screaming for help. I instructed Resident 2 to stop and go back to his room". RN 1 stated that Hskp 1 told her that she saw Resident 2 with his pants down on top FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1G5F11 Facility ID: CA020000125 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A396 (X3) DATE SURVEY COMPLETED 02/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of Resident 1. RN 1 stated, "I went to Resident 1 and saw Resident 1's gown and her brief were on the left side; I checked for semen and I didn't see any. I called the DON, Admin 1 and Medical Director. I did not call the police". During an interview on 12/11/18 at 2:40 p.m., Resident 2 stated he knew the black girl in the back; she couldn't talk, he may have been in her room, and if he was on top of her; she liked it. During an interview with the SS 1 on 1/4/19 at 9:08 a.m., the SS 1 stated I spoke to Resident 2 and did not write a note for the 11/18/18 incident. SS 1 further stated Resident 2 showed no insight to his behavior, denied he did it and because of his cognitive impairment and mental health issues, he was at risk for doing it again. Review of the facility's policy and procedure titled, "Abuse Prevention and Reporting", revised date of 11/14/17, showed under definitions that sexual abuse was defined as: "sexual harassment, sexual coercion, and sexual assault". The same policy continued by indicating that, "Staff is required to intervene, identify and correct situations where any type of abuse or suspected crimes may occur", and "The administrator/designee will take all measures to protect the resident from further potential abuse".

F608 SS=E Reporting of Reasonable Suspicion of a Crime F608 CFR(s): 483.12(b)(5)(i)-(iii) 02/12/2019 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1G5F11 Facility ID: CA020000125 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A396 (X3) DATE SURVEY COMPLETED 02/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. (iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to report allegations of abuse for 12 of 12 sampled residents (1,2,3,4,5,6,7,8,9,10,11,12) to the California Department of Public Health (State Agency). This failure presented placed residents at the facility in eminent danger of continued abuse when reporting to the proper authorities was neglected. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1G5F11 Facility ID: CA020000125 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A396 (X3) DATE SURVEY COMPLETED 02/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 12/11/18 at 12:50 p.m., the DON stated the process for reporting abuse is whoever receives a report of abuse is responsible for completing a document for an incident report and a SOC (SOC 341-Report of Suspected Dependent Adult/Elder Abuse Form) It is then to be given to the licensed staff; and then the licensed staff notifies the DON and the Admin 1. During an interview on 12/11/18 at 12:55 p.m., Admin 1 stated the Licensed Staff is responsible for both reporting alleged abuse to the appropriate authority/agency and notifying both, the DON and Admin 1. Admin 1 further stated the facility investigates first, before calling the police, because "these are psych patients." Review of a document titled, "Event Review for CDPH for the past 60 days," dated 12/11/18, showed incidents of abuse that were not reported to the State Agency: Alleged Sexual Abuse 12/8/18 - Resident 2 and Resident 1 11/17/18 - Resident 2 and Resident 1 Alleged Physical Abuse between Residents 12/1/18 - Resident 3 and Resident 4 11/21/18 - Resident 5 and Resident 6 11/20/18 - Resident 7 and Resident 8 11/19/18 - Resident 9 and Resident 10 11/17/18 - Resident 11 and Resident 12 11/14/18 - Resident 11 and Resident 4 In an interview on 12/11/18 at 2:45 p.m., Admin 2 stated, "I've only been here for six months and from what I understand, you don't have to send a SOC to the State Agency if the clients have Dementia." Admin 2 further stated that he had not sent notification of alleged abuse to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1G5F11 Facility ID: CA020000125 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A396 (X3) DATE SURVEY COMPLETED 02/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the State Agency, only to the Long Term Care State Ombudsman (LTCSO) and the local police department. During an interview on 12/11/18 at 3:04 p.m., the DON stated, "We were told if residents have a Dementia diagnosis, it's only the police department and LTCSO we have to report the abuse to. This is what we teach our staff as well." During an interview on 12/11/18 at 3:29 p.m., Admin 1 stated, "If people have Dementia you don't have to report it to the State Agency." In an interview with RN 1 on 12/21/18 at 2:45 p.m., RN 1 stated, "I completed the SOC and faxed it to the LTCSO and the police department." RN 1 then stated, "They told me if the patient have Dementia, we don't have to pass it to the State. Because they both have dementia that is why I didn't report it to the State." Review of the facility's policy titled "Abuse Prevention and Reporting," revised 11/14/17 showed, "If the alleged or suspected incident of a crime involves "physical abuse" AND it results in "serious bodily injury," then the mandated reporter shall make a telephone report to the local law enforcement agency immediately (call 911 if appropriate) and not later than two hours of observing, obtaining knowledge of or suspecting the physical abuse;' 'make a written report to the local ombudsman, Licensing Agency.... within two hours." Continued review of the same policy showed, "If the alleged or suspected "physical abuse or crime" DOES NOT result in "serious bodily injury," then the mandated reporter shall make a telephone report to the local law enforcement FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1G5F11 Facility ID: CA020000125 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A396 (X3) DATE SURVEY COMPLETED 02/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE within 24 hours ........ and make a written report to the local ombudsman and Licensing Agency." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1G5F11 Facility ID: CA020000125 If continuation sheet 10 of 10