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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440412
Report Date: 07/27/2023
Date Signed: 07/27/2023 11:51:32 AM

Document Has Been Signed on 07/27/2023 11:51 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
OAKLAND ASC, 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: 3DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:CAZARES, NANCY- AdministratorTIME COMPLETED:
12:00 PM
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On 7/27/2023 starting at 9:45 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with CAZARES, NANCY- Administrator (ADM) and explained the purpose of the visit. Administrators certificate (6020293735) is valid and expires on 10/15/2024. The facility’s fire clearance was approved for all four (4) ambulatory clients. Upon entry, LPA observed two (2) staff and one (1) client present during inspection.

Starting at 10:00 AM, LPA toured facility with ADM including but not limited to four (4) bedrooms, three (3) bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which all 4 bedrooms are private. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in clients’ common area bathroom was measured at 118.7 Degrees Fahrenheit. Clients’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Sharps and toxins were locked and inaccessible to clients'.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 1/15/2023. First aid kit was observed to be complete.


Continue on Lic809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NANCY CAZARES HOME
FACILITY NUMBER: 011440412
VISIT DATE: 07/27/2023
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Continued from Lic809

Starting At 10:28 AM, LPA reviewed 2 of 2 staff records. At 11:07 AM, LPA reviewed 3 of 3 clients' record which are current. At 11:23 PM, LPA reviewed a sample of 2 of 3 clients' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 8/3/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan (9 Pages)
· Liability Insurance
· Surety bond



No deficiencies cited during visit.




Exit interview conducted with ADM, and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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