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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600545
Report Date: 02/14/2024
Date Signed: 02/14/2024 12:46:12 PM

Document Has Been Signed on 02/14/2024 12:46 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ITHACA HOMEFACILITY NUMBER:
015600545
ADMINISTRATOR:DE LEON, VICTORFACILITY TYPE:
735
ADDRESS:32295 ITHACA STREETTELEPHONE:
(510) 400-3168
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 4DATE:
02/14/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Florante "Dan" Landingin, Direct Support StaffTIME COMPLETED:
01:00 PM
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On 02/14/2024 at 12:00PM, Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management Health and Safety check as a result of the department having an informal meeting with Licensees, Victor and Imelda de Leon on 02/13/2024. LPA met with Direct Support Staff, Florante "Dan" Landingin and explained the purpose of the visit. Dan phoned Licensee/Administrator, Victor de Leon to inform.

During the health and safety check, LPA observed a total of 2 Direct Support Staff (DSP) at the facility. The four residents were attending their day program. LPA toured facility with Direct Support Staff, Dan including but not limited to bedrooms, kitchen, bathroom, and common areas. Clients in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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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