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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440781
Report Date: 04/28/2022
Date Signed: 04/28/2022 05:31:59 PM

Document Has Been Signed on 04/28/2022 05:31 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:CROUSE HOMES, INC., THEFACILITY NUMBER:
011440781
ADMINISTRATOR:LAURA A CARTERFACILITY TYPE:
735
ADDRESS:237 CHERRY WAYTELEPHONE:
(510) 317-9016
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 15CENSUS: 14DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Hilario Siwa/House ManagerTIME COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Hilario 'Larry' Siwa, house manager, and informed the purpose of visit. LPA called and spoke with Laura Carter, administrator, who authorized Hilario Siwa, to sign and receive this report. LPA also met with other staff, Zenaida Siwa and Edna Yee.

Facility has LIC808 Mitigation Plan on file.

LPA toured the facility inside out with Hilario Siwa. LPA inspected the living room, dining area, kitchen, bathrooms, bedrooms, detached storage, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer and no touch temperature probe. Visitor's temperature and symptom checks are done at entry for visitors. Residents and staff are screened for COVID-19 symptoms and temperature checked daily. Facility keeps record of proof of vaccination of residents and staff, and antigen test kits are readily available. Supplies of PPEs were checked.

Fire extinguisher checked and observed fully charge with tag showed serviced November 8, 2021. First aid kit was observed complete with manual. Hot water temperature in one of the common bathrooms checked and measured at 110.4 degrees Fahrenheit.


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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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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: CROUSE HOMES, INC., THE
FACILITY NUMBER: 011440781
VISIT DATE: 04/28/2022
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 LPA observed the following:
1. No COVID-19 signages posted all throughout the facility and front entrance door.
2. No hand washing posters in the kitchen and bathrooms.
3. Trash bins no lids.
4. No visitor's log.
5. PPEs not sufficient for 30 days for 5 staff. There's only 12 N95 respirators, 100 disposable gowns and 20 disposable surgical masks.
6. No paper towel with dispenser available for hand drying in the bathrooms.
LPA verified and Hilario and :Laura stated the staff are not fit tested for N95 respirator. Staff does not check visitors for proof of COVID-19 vaccination nor record the temperature readings when checked.

Administrator to submit the following updated documents by May 12, 2022:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan

No deficiency cited during today's visit.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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