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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600554
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:47:26 PM


Document Has Been Signed on 05/16/2024 04:47 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:A HOME OF OUR OWNFACILITY NUMBER:
015600554
ADMINISTRATOR:FEKETE, EMILYFACILITY TYPE:
740
ADDRESS:2268 MARINA AVENUETELEPHONE:
(925) 443-6218
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Emily Fekete, AdministratorTIME COMPLETED:
04:55 PM
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On 5/16/2024 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Emily Fekete and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory residents of which 3 residents maybe under hospice care.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, common areas, kitchen, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 10/12/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 116 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. Last disaster drill was conducted on 3/21/2024.

LPA reviewed 5 residents and 4 staff files starting at 11:10AM. LPA interviewed 2 residents and 2 staff at 2:30PM. LPA reviewed a sample of resident's medications starting at 3:00PM.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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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