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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440339
Report Date: 06/08/2022
Date Signed: 06/08/2022 05:05:11 PM

Document Has Been Signed on 06/08/2022 05:05 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:PIROUNAKIS, INC.FACILITY NUMBER:
011440339
ADMINISTRATOR:MARY PIROUNAKISFACILITY TYPE:
735
ADDRESS:17031 RAGLAND ST.TELEPHONE:
(510) 276-2301
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 12CENSUS: 12DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mary Pirounakis/AdministratorTIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Antonella Baltazar and Michael Revill, and informed the purpose of visit. Mary Pirounakis, administrator, arrived after several minutes. LPA also spoke with Margaret 'Rita' Revill, co-adminstrator, over the phone.

Facility has an approved LIC808 Mitigation Plan on file.

LPA started the inspection with Antonella Baltazar and continued with Mary Pirounakis. LPA inspected the living room, dining area, kitchen, one of the bathrooms, bedrooms, garage, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer and no touch temperature probe, Visitor's log. Visitor's temperature and symptom checks are done at entrance/ Residents and staff are screened for COVID-19 symptoms and temperature checked daily. Facility keeps record of proof of vaccination of residents and staff, and antigen test kits are readily available. Supplies of PPEs were checked. and observed adequate for 30 days for 7 staff. All staff were fit tested for N95 respirator and record showed conducted July 5, 6 and 7, 2021.

Fire extinguishers checked and observed fully charge with tags showed serviced January 27, 2022. Hot water temperature in one of the bathrooms was tested and measured at 112 degrees Fahrenheit.

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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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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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: PIROUNAKIS, INC.
FACILITY NUMBER: 011440339
VISIT DATE: 06/08/2022
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On this day, June 8, 2022, LPA obtained copies of the following updated documents:
1. LIC308 Designation of Facility Responsibility
2, LIC400 Affidavit Regarding Client/Resident Cash Resources
3. LIC500 Personnel Report
4. LIC610D Emergency Disaster Plan (9 pages)
5. Proof of Surety Bond coverage
6, N95 Fit Testing Record

LPA reminded that new Infection Control Plan should be submitted by June 30. 2022.

No deficiency cited during today's visit.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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