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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200130
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:05:53 PM

Document Has Been Signed on 06/12/2024 03:05 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:BISHOP ADULT RES. CAREFACILITY NUMBER:
019200130
ADMINISTRATOR/
DIRECTOR:		LILIBETH ORDINIZAFACILITY TYPE:
735
ADDRESS:758 BISHOP AVETELEPHONE:
(510) 586-0266
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Mayona Galang, Care Staff TIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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On this day, June 12, 2024, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection. LPA met with staff, Mayona Galang, and informed the reason for visit. LPA called and spoke over the phone with Lilibeth 'Beth' Ordiniza, administrator. Administrator was not able to attend and gave verbal permission for staff Mayona to sign the report. LPA observed no client at the facility because they all attended day program.

LPA toured the facility inside out with Mayona. LPA inspected the kitchen, dining areas, living room and family rooms. Bedrooms, bathroom, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and storage for cleaning supplies were observed locked.

Facility has carbon monoxide and smoke detectors that were tested and observed functional. Facility conducts earthquake and fire drills at least every quarter, and records showed last conducted December 2023 and November 2023 respectively. Fire extinguisher checked, observed fully charge with tag showed serviced June 4, 2024. Hot water temperature was tested.

LPA reviewed 5 staff and 5 residents records and interviewed 2 staff. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. P&I were checked against records.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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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