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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200135
Report Date: 07/13/2022
Date Signed: 07/14/2022 09:19:22 AM

Document Has Been Signed on 07/14/2022 09:19 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ARC OF THE EAST BAY WALPERT AVP PROGRAM, THEFACILITY NUMBER:
019200135
ADMINISTRATOR:TUTTLE, RENEEFACILITY TYPE:
775
ADDRESS:1101 WALPERT STREETTELEPHONE:
(510) 357-3569
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 200CENSUS: 39DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Renee Tuttle/Program DirectorTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with Program Director Renee Tuttle, and informed the purpose of visit.

Facility has an approved LIC808 Mitigation Plan on file. Director of Operation Joanne Rolle submitted the facility's new Infection Control Plan which LPA received on June 23, 2022.

LPA toured the facility inside out with Renee Tuttle. LPA inspected building #s 1, 2, 3, 4 (Larc Hall), 5 (front office building), and 1111 (building at the back of the facility area). Building #1111 is for management/administration use. LPA observed screening station by the front entrance in the front office building equipped with hand sanitizer, no touch temperature probe, surgical masks, disposable gloves and gowns, and Visitor's Log. Visitor's temperature and symptom checks are done at the entrance. Clients and staff are screened for COVID-19 symptoms, and temperature checked and recorded daily. Facility keeps record of proof of vaccination of staff. LPA observed a central screening stations with hand sanitizer, sanitizing wipes, disposable surgical masks and disposable gloves in the other buildings. Supplies of PPEs checked and antigen test kits are readily available. Bathroom lavatories in all buildings were observed with liquid soap and paper towels in a dispensers. Covid-19 signages/posters were observed in all buildings. There were 39 clients/program attendees during inspection, and LPA observed they were 6 feet or more apart from each other and spread out in building 1, 2, 3 and 4. Staff were fit tested for N95 respirators.

Fire extinguishers checked and observed fully charge with tags showed serviced September 28, 2021. Hot water temperature in the common bathroom in building # 2 was tested and measured at 107.6 degrees Fahrenheit.

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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ARC OF THE EAST BAY WALPERT AVP PROGRAM, THE
FACILITY NUMBER: 019200135
VISIT DATE: 07/13/2022
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LPA observed the trash bins with lids that are not touch free in all the buildings.

The following updated documents to be submitted by July 27, 2022:
1. LIC308 Designation of Facility Responsibility.
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)

No deficiency cited during today's inspection.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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