<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601252
Report Date: 05/11/2022
Date Signed: 05/11/2022 10:42:53 AM


Document Has Been Signed on 05/11/2022 10:42 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: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:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Cristina Nica, LicenseeTIME COMPLETED:
10:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/11/2022 at 8:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with licensee, Cristina Nica.

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, kitchen, common areas, garage, and outdoor areas. LPA observed cough etiquette and physical distancing posted in the common areas. All sinks were equipped with soap and paper towel. Hand washing posters were posted at bathrooms and sinks.

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 food and paper supplies are sufficient.

No deficiencies are being 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: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3