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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440412
Report Date: 07/18/2024
Date Signed: 07/18/2024 12:35:30 PM

Document Has Been Signed on 07/18/2024 12:35 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:NANCY CAZARES HOMEFACILITY NUMBER:
011440412
ADMINISTRATOR/
DIRECTOR:		CAZARES, NANCYFACILITY TYPE:
735
ADDRESS:36168 PERKINS STREETTELEPHONE:
(510) 794-0677
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 4CENSUS: 3DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Nancy Cazares, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 7/18/2024 at 10:55am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Nancy Cazares, Licensee, and explained the purpose of the visit. The administrator currently holds a certificate (#6021354735) that expires on 11/24/2024. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, garage, common area and back yard. The facility consists of four (4) bedrooms and three (3) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 77 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 114.6 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Emergency disaster plan last updated 1/15/2024. Fire extinguisher last serviced on 1/28/2024. Fire drill last conducted 5/19/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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 2
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: NANCY CAZARES HOME
FACILITY NUMBER: 011440412
VISIT DATE: 07/18/2024
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Continued from LIC809.

Two (2) staff records and three (3) clients' records were reviewed. LPA reviewed P & I.

The following forms are to be updated and submitted to CCLD by 7/25/2024:
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC 610D Emergency disaster plan (last page)
  • LIC 500 (Personnel Record)
  • LIC 308 (Designation of facility responsibility)

No deficiencies cited during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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