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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440776
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:09:23 PM


Document Has Been Signed on 03/29/2022 03:09 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:BAYWOOD COURTFACILITY NUMBER:
011440776
ADMINISTRATOR:DIPA GUPTAFACILITY TYPE:
740
ADDRESS:21966 DOLORES STREETTELEPHONE:
(510) 733-2422
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:72CENSUS: 45DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Dipa Gupta, AdminstratorTIME COMPLETED:
03:25 PM
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On 3/29/2022 at 12:50 PM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Dipa Gupta and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, random apartments, common areas, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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