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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601132
Report Date: 06/11/2021
Date Signed: 06/11/2021 01:48:56 PM

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:AT HOME ELDERLY CAREFACILITY NUMBER:
015601132
ADMINISTRATOR:DELUNA, MARIA LOURDES D.FACILITY TYPE:
740
ADDRESS:15734 VIA ESMONDTELEPHONE:
(510) 278-3906
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:5CENSUS: 3DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Maria DelunaTIME COMPLETED:
01:55 PM
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On 06/11/2021 at 12:36pm, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Staff (S1) and explained the purpose of the visit. Licensee Maria Deluna arrived at approximately 12:50pm.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and backyard. LPA observed cough etiquette and physical distancing signs posted in the common areas. All hand washing stations were equipped with soap, paper towels and garbage with a lid. Hand washing posters were posted at hand washing stations.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food and paper supplies are sufficient. Screening questions, visitor's sign in and temperature log were maintained at the facility for all visitors. Resident and staff's temperatures are checked daily. Common areas are disinfected three times a day.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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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