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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200086
Report Date: 05/18/2022
Date Signed: 05/31/2022 06:02:58 PM

Document Has Been Signed on 05/31/2022 06:02 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:SIR FRANCES ANN RESIDENTIALFACILITY NUMBER:
019200086
ADMINISTRATOR:DELLA A. CHAMBERS-BREWERFACILITY TYPE:
735
ADDRESS:1739 SCENICVIEW COURTTELEPHONE:
(510) 357-6995
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 6CENSUS: 6DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:05 PM
MET WITH:Clarisse Takie, StaffTIME COMPLETED:
06:15 PM
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On 5/18/2/22 at 3:19pm, Licensing Program Analyst (LPA) C. Lin arrived at facility and learned that there was Covid-19 outbreak, all clients and staff were tested Covid-19 positive. LPA left facility.

On 5/31/22 at 5:05pm, LPA C. Lin arrived unannounced to conduct Infection Control Inspection. LPA met with staff Clarisse Takile and disclosed the purpose of the visit. LPA spoke with the Administrator on the phone who authorized staff to sign on the report.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. 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. Cough/sneeze etiquette and hand washing posters were observed.

Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors.

No deficiency cited during visit. Exit interview conducted with staff, and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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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