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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601366
Report Date: 08/26/2022
Date Signed: 08/26/2022 02:13:43 PM


Document Has Been Signed on 08/26/2022 02:13 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:FOOTPRINT CARE HOMEFACILITY NUMBER:
015601366
ADMINISTRATOR:ALMOCERA, SOLEDADFACILITY TYPE:
740
ADDRESS:4647 HANSEN AVENUETELEPHONE:
(510) 797-8719
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 2DATE:
08/26/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Care Staff, Gloria ZuluetaTIME COMPLETED:
02:15 PM
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On today’s date, at 1:30PM. Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct a POC visit. LPA and LPM was greeted by Care staff, Gloria Zulueta and explained the purpose of the visit.

On 8/19/2022 LPA conducted an annual infection control visit. Facility was cited a type A violation under California Code of Regulations (CCR) 87203 with correction due back by 8/20/2022.

87203 Fire Safety:

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

On 8/19/2022 visit it was noted that smoke detector was not operable. As of today, LPA has not received any proof of correction from the facility. LPA and LPM toured the facility with care staff Gloria Zulueta. Each smoke detector was tested in the home. The smoke detectors in the front room and hallway near bathroom are not operable on today's visit.

Continue on Lic809-C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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 2


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: FOOTPRINT CARE HOME
FACILITY NUMBER: 015601366
VISIT DATE: 08/26/2022
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Continued on Lic809-C

Civil Penalties in the amount of $600 is being assessed today for the period of 8/21/2022 to 8/26/2022 for failure to meet POC date for deficiency 87203. Facility is subject to ongoing penalties until citation is corrected.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2