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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601481
Report Date: 01/27/2023
Date Signed: 01/27/2023 04:33:36 PM


Document Has Been Signed on 01/27/2023 04:33 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:COMMON DESTINYFACILITY NUMBER:
015601481
ADMINISTRATOR:TOM, MARVINFACILITY TYPE:
740
ADDRESS:34209 SYLVESTER DRIVETELEPHONE:
(510) 794-4931
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY:6CENSUS: 6DATE:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Tom Marvin and Yuan Hong- LicenseesTIME COMPLETED:
04:40 PM
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On 1/27/2023, at 3:50 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by Tom Marvin and Yuan Hong- Licensees and explained the purpose of todays visit.

During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All sharps and toxins were locked up and inaccessible to residents in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 110.2 Degrees F in common area bathroom. Fire extinguisher was last serviced on 9/28/2022. Facilities room temperature is maintained at 68 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are functional. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care.

During record review, LPA observed facility has a copy of their Infection Control Plan and Disaster Plan on file.

No deficiencies cited during today's visit.

Exit interview conducted with Licensees and copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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