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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600131
Report Date: 12/29/2022
Date Signed: 12/29/2022 03:45:02 PM

Document Has Been Signed on 12/29/2022 03:45 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:MV HOMEFACILITY NUMBER:
015600131
ADMINISTRATOR:TERESITA MCLAUGHLINFACILITY TYPE:
735
ADDRESS:32444 NANCY COURTTELEPHONE:
(510) 441-2648
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator, Teresita McLaughlinTIME COMPLETED:
03:55 PM
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On 12/29/2022 starting at 2:40 PM, Licensing Program Analyst (LPA) Liridon Fici arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator Teresita McLaughlin and disclosed the purpose of the visit.

Upon entry, LPA’s temperature was checked by staff. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, common areas, and outdoor areas. There is one central entry point for universal screening for staff, clients, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE.

Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of medication accessible to staff. Water temperature is measured at 116.5 Degrees F. Fire extinguisher was last serviced on 11/16/2022. Carbon monoxide and smoke detectors are functional. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care.

Facility has Infection Control Plan, Emergency Disaster Plan, and maintains record of routine screening for clients, staff, and visitors


No deficiency cited during visit.

Exit interview conducted with Administrator, and a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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