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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600507
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:21:59 PM


Document Has Been Signed on 01/20/2023 12:21 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:C & R HOME FOR THE ELDERLYFACILITY NUMBER:
015600507
ADMINISTRATOR:TEOFILO CRIS SANQUEFACILITY TYPE:
740
ADDRESS:34819 CLOVER STREETTELEPHONE:
(510) 324-0627
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 3DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Lorraine Roma, CaregiverTIME COMPLETED:
12:30 PM
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On 1/20/2023, at 11:25 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an Infection Control Inspection. LPA met with Lorraine Roma, Caregiver and explained the purpose of the visit. Licensee, Precilla San Miguel arrived at 11:51 AM.

Upon entry, LPA's temperature was checked. LPA observed screening station outside on porch that contained hand sanitizer and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hot water temperature in the shared residents’ bathroom was measured at 109.7 Degree Fahrenheit. Fire extinguisher was last serviced on 11/22/2022.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE and paper supplies are sufficient.

The following forms to be updated and submitted to CCLD by 1/27/2023:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continue on LIC809C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: C & R HOME FOR THE ELDERLY
FACILITY NUMBER: 015600507
VISIT DATE: 01/20/2023
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Continued from LIC809

-LIC610E Emergency Disaster Plan
-LIC9282 Infection Control Plan

There were no deficiencies observed during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2