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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440412
Report Date: 08/18/2022
Date Signed: 08/18/2022 10:16:23 AM

Document Has Been Signed on 08/18/2022 10:16 AM - 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:NANCY CAZARES HOMEFACILITY NUMBER:
011440412
ADMINISTRATOR:CAZARES, NANCYFACILITY TYPE:
735
ADDRESS:36168 PERKINS STREETTELEPHONE:
(510) 794-0677
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 4CENSUS: 4DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Nancy Cazares-AdministratorTIME COMPLETED:
10:20 AM
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On today’s date, at 9:35 AM, Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct an Annual Infection Control Visit. LPA and LPM was greeted by Administrator Mia Moe at front door entrance.

During the inspection, LPAs toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA and LPM observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA and LPM observed paper supplies and PPEs are sufficient. Common areas are disinfected frequently throughout the day. Water temperature is measured at 114.3. Fire extinguisher was last serviced on 2-16-2022. Carbon monoxide and smoke detector are operable. Facility passages inside and out free of obstruction and does not pose a health and safety risk for persons in care.

During record review, LPA and LPM observed facility has a copy of their Infection Control Plan on file.

No deficiencies cited during visit.

Exit interview conducted with Administrator and copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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