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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600545
Report Date: 05/21/2024
Date Signed: 05/21/2024 03:32:33 PM

Document Has Been Signed on 05/21/2024 03:32 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:ITHACA HOMEFACILITY NUMBER:
015600545
ADMINISTRATOR/
DIRECTOR:		DE LEON, VICTORFACILITY TYPE:
735
ADDRESS:32295 ITHACA STREETTELEPHONE:
(510) 400-3168
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 4DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Victor De Leon, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On today date Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Annual/Required inspection. LPA met with caregiver Florante Landingin, and Administrator Victor De Leon (Administrator Certificate pending to arrival). Facility is vendorized by Regional Center of the East Bay as a level 3 home.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which all 4 bedrooms are occupied by the clients, 1 is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 73 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 117.1 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene’s were available for clients. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/26/2023. Emergency Disaster Drill was last posted on 5/21/2024. First aid kit was observed to be complete. Fire drill was last conducted on 5/19/2024.

Report continues on 809 C…
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ITHACA HOME
FACILITY NUMBER: 015600545
VISIT DATE: 05/21/2024
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At 12:00 PM, LPA reviewed 4 of 4 residents records. At 1:30 PM, LPA reviewed 2 staff records and 2 of 2 have current first aid training and associated to the facility. At 2:30 PM, LPA reviewed a sample of 4 of 4 resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 05/24/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 D Emergency Disaster Plan


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC809 (FAS) - (06/04)
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