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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601095
Report Date: 07/13/2022
Date Signed: 07/13/2022 03:55:46 PM


Document Has Been Signed on 07/13/2022 03:55 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:HERITAGE ESTATESFACILITY NUMBER:
015601095
ADMINISTRATOR:BATTISTI, STEVEFACILITY TYPE:
740
ADDRESS:900 E STANLEY BLVDTELEPHONE:
(925) 373-3636
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:65CENSUS: 47DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Steve Battisti, Executive Director
Raymond Madrid, Health & Wellness Nurse		TIME COMPLETED:
04:10 PM
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On 7/13/2022 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Executive Director, Steve Battisti and explained the purpose of the visit. LPA also met with Health and Wellness Nurse, Raymond Madrid.

Upon entry, LPA's temperature was checked and asked to fill out COVID-19 questionnaire on the automated kiosk. LPA observed hand sanitizer at screening station. LPA and Nurse, Raymond toured facility including but not limited to bedrooms, bathrooms, kitchen, and common areas. LPA observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All bathrooms were equipped with soap, paper towel and garbage can with a lid. Hand washing posters were posted at bathrooms.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed FIT tested was completed for staff and completion document was reviewed. LPA observed PPE, food supplies, and paper supplies are sufficient.

No deficiencies were 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: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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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