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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600456
Report Date: 06/18/2024
Date Signed: 07/17/2024 02:45:21 PM

Document Has Been Signed on 07/17/2024 02:45 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LAHANA WAY HOMEFACILITY NUMBER:
015600456
ADMINISTRATOR/
DIRECTOR:		TERESITA MCLAUGHLINFACILITY TYPE:
735
ADDRESS:39648 LAHANA WAYTELEPHONE:
(510) 490-3283
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 6DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Bernadeth Relon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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On 6/18/2024 at 10:45 AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Bernadeth Relon- Administrator (ADM) and explained the purpose of the visit. Administrators certificate (6041163735) is valid and expired on 6/15/2024. The facility’s fire clearance was approved for all six (6) non- ambulatory clients. Upon entry, LPA observed three (3) staff and four (4) clients present during inspection.

Starting at 11:00 AM, LPA toured facility with ADM including but not limited to six (6) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all 4 bedrooms are private, one room is shared, and one staff room. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in clients’ common area bathroom was measured at 109.8 Degrees Fahrenheit. Clients’ bathrooms are equipped non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Sharps and toxins were locked and inaccessible to clients'.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 12/11/2023. First aid kit was observed to be complete.



Continue on LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LAHANA WAY HOME
FACILITY NUMBER: 015600456
VISIT DATE: 06/18/2024
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Continued from LIC809

LPA reviewed three (3) staff records and Six (6) clients' record which are current and complete. LPA also reviewed P & I and a sample of medication.

No deficiencies observed during visit.

The following forms to be updated and submitted to CCLD by 06/25/2024:

· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC610D Emergency Disaster Plan
· LIC308 Designation of facility responsibility

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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