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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601501
Report Date: 02/07/2022
Date Signed: 02/07/2022 05:28:16 PM

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:LANDMARK VILLAFACILITY NUMBER:
015601501
ADMINISTRATOR:DIANE PEDERSONFACILITY TYPE:
740
ADDRESS:21000 MISSION BLVD.TELEPHONE:
(510) 276-2872
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:140CENSUS: 74DATE:
02/07/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH: Executive Director Diane Pederson TIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a complaint (Control # 15-AS-20220203093410). LPA met with Executive Director (ED) Diane Pederson and informed the purpose of visit.

LPA conducted inspection with ED. LPA inspected the common area, lobby. dining area, kitchen, side patio, and selected 5 apartments for inspection. Hallways and passageways were observed free of obstructions.

LPA observed the following:
1. Hand washing poster in each of the five apartments but not in the kitchenettes.
2. No trash bin with pedal operated lid outside the isolation room.

No deficiency cited during this visit.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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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