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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200038
Report Date: 09/01/2021
Date Signed: 09/01/2021 01:18:35 PM

Document Has Been Signed on 09/01/2021 01:18 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:WALLACE PLACE CARE HOMEFACILITY NUMBER:
019200038
ADMINISTRATOR:MARISSA RUBIOFACILITY TYPE:
735
ADDRESS:5469 WALLACE PLACETELEPHONE:
(408) 807-2467
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 6DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Marissa RubioTIME COMPLETED:
01:30 PM
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On 09/01/2021 at 11:50am, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Licensee Marissa Rubio and explained the purpose of the visit.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and backyard. LPA observed COVID-19 signs posted throughout the facility. LPA observed food, paper, and PPE supplies are sufficient. Common areas are disinfected frequently throughout the day. Bathrooms are stocked with soap, paper towels, and trash can with a lid. Smoke detector and carbon monoxide detector were working.

During record review, LPA observed facility has a copy of Mitigation Plan on file.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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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