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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601368
Report Date: 03/11/2022
Date Signed: 03/11/2022 02:37:43 PM


Document Has Been Signed on 03/11/2022 02:37 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:AGEWAY BOARDING CAREFACILITY NUMBER:
015601368
ADMINISTRATOR:DAYEH, VICTORIA & ANAFACILITY TYPE:
740
ADDRESS:2716 MEADOWLARK DRIVETELEPHONE:
(510) 475-8869
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 2DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mihael Dayeh, AdminsitratorTIME COMPLETED:
02:45 PM
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On 3/11/2022 at 1:30 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPA was greeted by Care Staff, Renato Tisico and LPA explained the purpose of the visit. Administrator, Mihael Dayeh later arrived at 2:25 PM.

During the Infection Control Inspection, LPA toured facility with Care Staff including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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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