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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601493
Report Date: 10/14/2022
Date Signed: 10/14/2022 11:36:01 AM


Document Has Been Signed on 10/14/2022 11:36 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:AGEWAY BOARDING CARE #3FACILITY NUMBER:
015601493
ADMINISTRATOR:DAYEH, ANAFACILITY TYPE:
740
ADDRESS:2636 NEVADA STREETTELEPHONE:
(510) 475-8869
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
10/14/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Marina Velasquez, Lead StaffTIME COMPLETED:
11:45 AM
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On 10/14/2022 at 10:50AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management health & safety check. LPA met with the lead staff and explained the purpose of the visit. LPA spoke with Administrator on the phone, Administrator authorized the lead staff to sign on the report.

Upon entry, LPA toured the facility. LPA observed facility had sufficient food supplies in the kitchen and garage. LPA also observed adequate supply of PPE in the garage. LPA observed bathrooms has sufficient soap and paper towel supplies. Cough/sneeze etiquette and hand washing posters were observed posted in common areas and bathrooms. LPA observed the room temperature was 70 Fahrenheit degree, water temperature was 107 Fahrenheit degree, and fire extinguishers were last inspected on 1/26/22.

Sufficient staffing was observed during visit. Staff was observed wearing surgical masks. Pathways and hallways were observed free of obstruction and fire hazards.

There were no imminent health/safety concerns on today's date.

No deficiency cited. Exit interview conducted with Lead staff and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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