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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440620
Report Date: 06/27/2022
Date Signed: 06/27/2022 12:44:38 PM

Document Has Been Signed on 06/27/2022 12:44 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:KEYSTONE ADULT LEARNING CENTERFACILITY NUMBER:
011440620
ADMINISTRATOR:BRUM, NANCYFACILITY TYPE:
775
ADDRESS:1241 QUARRY LANE, SUITE 145TELEPHONE:
(925) 484-5330
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY: 30CENSUS: 11DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Nancy Brum, Executive DirectorTIME COMPLETED:
12:59 PM
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On 6/27/2022 at 10:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Executive Director (ED), Nancy Brum and explained the purpose of the visit.

Upon entry, LPA's temperature was checked and asked to fill out COVID-19 questionnaire. LPA observed the day program was conducting in-person services during inspection. LPA toured facility including but not limited to activity rooms, common areas, bathrooms, and kitchen. LPA observed facility have cough etiquette, infection control protocol, signs & symptoms, and social distancing posted in common areas. All hand washing stations were equipped with soap and paper towels. Facility has implement daily screenings with all staff, clients, and visitors.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPEs, soap, and paper supplies are sufficient. Facility has a log to document all temperature screening for clients, staff, and visitors. Staff that will be working with COVID positive clients had FIT testing for N95 mask. LPA reviewed FIT testing results for those staff.

No deficiency is being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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