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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600585
Report Date: 11/10/2022
Date Signed: 11/10/2022 10:56:14 AM

Document Has Been Signed on 11/10/2022 10:56 AM - 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:VILLA MONTGOMERYFACILITY NUMBER:
015600585
ADMINISTRATOR:ADORA ROSE M SANTIAGOFACILITY TYPE:
735
ADDRESS:22240 MONTGOMERY STREETTELEPHONE:
(510) 886-1813
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 20CENSUS: 14DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Care Staff, Aurarubilyn BucuTIME COMPLETED:
11:10 AM
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On 11/10//2022, at 10:18 AM, Licensing Program Analyst (LPA) Liridon Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by Care Staff, Aurarubilyn Bucu. Licensee Rose Adora gave care staff consent for LPA to toured the facility on her behalf.

During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All sharps and toxins were locked up and inaccessible to clients in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 105.1 degrees F. Fire extinguisher was last serviced on 10/21/2022. Facilities room temperature is maintained at 68 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are operable. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care.

During record review, LPA observed facility has a copy of their Infection Control Plan and Disaster Plan on file

No deficiencies cited during today's visit.

Exit interview conducted with Care staff, and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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