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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600613
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:41:11 PM

Document Has Been Signed on 10/16/2024 01:41 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:NC HOMEFACILITY NUMBER:
015600613
ADMINISTRATOR/
DIRECTOR:		MCLAUGHLIN, TERESITAFACILITY TYPE:
735
ADDRESS:2729 DOWE AVENUETELEPHONE:
(510) 324-5622
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Teresita McLaughlinTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On this day at around 10:15 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Administrator Teresita McLaughlin. LPA explained to Administrator the purpose of the visit. The facility is a Level 4C home vendored by the Regional Center of the East Bay (RCEB). Facility has an approved fire clearance for 6 non ambulatory clients. Five clients and three staff were observed during the visit. One client was out with family.

LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, kitchen, dining area, backyard and living area. There was sufficient lighting throughout the facility. No bodies of water were observed. There was sufficient supply of perishable and non-perishable foods. Sufficient blankets, sheets, towels, hand towels were observed. Fire extinguisher in the kitchen area was observed to be full and last inspected on 12/12/23. First aid kit was observed complete and updated. Smoke detector and carbon monoxide were tested and observed operational. Hot water measured at 105.4 Fahrenheit.

Last fire drill was completed on 8/17/24 and last earthquake drill was conducted on 9/30/24. At 10:45 am, LPA reviewed P&I money and log with the Administrator. The facility has sufficient amount of surety bond to cover amount of money being handled at one time.

At 11 AM, LPA reviewed 5 client files and 4 staff files. At 12:30 PM, LPA reviewed medications and Medication Administration Record (MAR).
continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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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: NC HOME
FACILITY NUMBER: 015600613
VISIT DATE: 10/16/2024
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At 11 AM, LPA reviewed 5 client files and 3 staff files. All staff are fingerprint cleared and associated to the facility. At 12:30 PM, LPA reviewed medications and Medication Administration Record (MAR).

No deficiencies were noted during this visit.

A copy of this report was provided to the Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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