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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600456
Report Date: 06/10/2022
Date Signed: 06/10/2022 04:55:42 PM

Document Has Been Signed on 06/10/2022 04:55 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:LAHANA WAY HOMEFACILITY NUMBER:
015600456
ADMINISTRATOR:TERESITA MCLAUGHLINFACILITY TYPE:
735
ADDRESS:39648 LAHANA WAYTELEPHONE:
(510) 490-3283
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 6DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:56 PM
MET WITH:Bernadeth, Relon- AdministratorTIME COMPLETED:
05:00 PM
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On 06/10/2022 at 3:56pm, Licensing Program Analyst (LPAs) L. Fici & C. Lin arrived unannounced to conduct an annual Infection Control Inspection. LPAs met with Administrator (ADM), Bernadeth and explained the purpose of the visit.

LPAs toured facility with including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. 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. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Water temperature was measured at 119.5. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. 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. Fire extinguisher was observed serviced 12/8/2021. LPAs observed facility passages inside and out free of obstruction.



Continue on Lic809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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: LAHANA WAY HOME
FACILITY NUMBER: 015600456
VISIT DATE: 06/10/2022
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Continued on Lic809C

The following form are to be updated and submitted to CCLD By 6/17/2022.
- LIC500- Personnel Report

No deficiencies cited during visit. Exit interview conducted with ADM and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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