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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600218
Report Date: 02/28/2023
Date Signed: 02/28/2023 10:16:32 AM

Document Has Been Signed on 02/28/2023 10:16 AM - 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:HAYWARD EMPLOY AMERICAFACILITY NUMBER:
015600218
ADMINISTRATOR:GARRETTE, ELECIAFACILITY TYPE:
775
ADDRESS:2483 INDUSTRIAL PARKWAYTELEPHONE:
(510) 785-2284
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 30CENSUS: 8DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rocel Cooperrider/Program DirectorTIME COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with Program Director (PD) Rocel Cooperrider, and informed the purpose of visit.

Facility has an approved LIC808 Mitigation Plan. Facility has not submitted the LIC9283 Infection Control Plan.

LPA toured the facility inside out with PD. LPA inspected the reception area, dining rooms, media and activity rooms, bathrooms, library and isolation/quiet room,

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked. Facility has antigen test kits readily available. COVID-19 signages were observed all throughout the facility. Bathroom lavatories were observed with liquid soap and paper towel in dispenser for hand drying. Trash cans were observed with no touch lids.

Fire extinguishers checked, and observed fully charge with tags showed serviced April 11, 2022. Hot water temperature in one of the common bathrooms was tested and measured at 105 degrees Fahrenheit.

LPA observed supply of N95 respirators and disposable gowns not sufficient for 14 staff for 30 days.


.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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: HAYWARD EMPLOY AMERICA
FACILITY NUMBER: 015600218
VISIT DATE: 02/28/2023
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Program Director to submit the following by March 14, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. N95 fit testing records/certificates
5. LIC9283 Infection Control Plan

No citation issued.

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

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
LIC809 (FAS) - (06/04)
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