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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601252
Report Date: 06/09/2021
Date Signed: 06/09/2021 11:52:18 AM

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:PLEASANTON SENIOR CARE VILLAFACILITY NUMBER:
015601252
ADMINISTRATOR:NICA, CRISTINAFACILITY TYPE:
740
ADDRESS:2609 CORTE ELENATELEPHONE:
(925) 600-8512
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:6CENSUS: 5DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Cristina Nica, LicenseeTIME COMPLETED:
12:06 PM
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On 6/9/2021 at 9:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with staff, Shantau Mcleod and explained the purpose of the visit. Licensee, Cristina Nica arrived 30 minutes later.

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

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 PPE, food supplies, and paper supplies are sufficient.

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102.

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: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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