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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600386
Report Date: 07/24/2024
Date Signed: 07/24/2024 01:55:47 PM


Document Has Been Signed on 07/24/2024 01:55 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:HARTNELL HOME CAREFACILITY NUMBER:
015600386
ADMINISTRATOR:PURUGANAN,VICTORIA C.FACILITY TYPE:
740
ADDRESS:2041 HARTNELL STREETTELEPHONE:
(510) 489-7290
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 2DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jezrael Pascual, Facility ManagerTIME COMPLETED:
02:30 PM
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On 07/24/2024 at 9:45am, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced 1-Year required inspection. LPA met with Nelai Punzalan, Caregiver, and explained the purpose of the visit. Victoria Puruganan, Administrator was not available during the inspection. Jezrael Pascual, Facility Manager later arrived at 12:10pm. The Administrator currently holds a certificate (#6019519740) that expires on 10/24/2024. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA got verbal permission for Facility Manager to sign the report.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguishers were last serviced on 08/16/2023. Emergency Disaster Plan was posted. First aid kit was observed to be complete.

LPA reviewed five (2) residents file and four (2) staff files the files reviewed were complete.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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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