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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200158
Report Date: 01/18/2022
Date Signed: 01/18/2022 04:27:54 PM

Document Has Been Signed on 01/18/2022 04:27 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:MISSION HOPE DAY PROGRAM- HAYWARDFACILITY NUMBER:
019200158
ADMINISTRATOR:JAY FRANCIS Y GAMEZFACILITY TYPE:
775
ADDRESS:21328 MISSION BLVD.TELEPHONE:
(510) 888-9231
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 45CENSUS: 0DATE:
01/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Charlie Olivar/Program DirectorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Program Director Charlie Olivar and informed the purpose of visit. LPA also met with other staff, Yolanda Maramag, Annie Maquiling. Ligaya Jauss, Maria Christina Gonzales, Emma Ustare, Augustine Udoh, Sharon Alvarez, Maria Melinda Gamata, Rico Oliva, Carl Angelo Arceo, Charlie John Dimaya who are all fingerprint cleared and associated to this facility. The facility is currently providing program/activities to clients remotely via Zoom.

Facility has an approved LIC808 COVID-19 Mitigation Plan. Staff were fit tested for N95 respirator.

LPA inspected the facility inside and out with Charlie Olivar. LPA observed screening stations located near the front entrance with visitor's log, hand sanitizer, surgical masks and no touch temperature probe in building # 1 and building # 2. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and clients and recorded daily. Trash bins were observed with pedal operated lids. Centrally stored PPEs inspected and observed good for 30 days. Facility has updated visitor's poster posted on building # 1 entrance door. Both buildings have COVID-19 signages/posters.

Fire extinguishers were observed fully charge and tags showed serviced December 8, 2021. Smoke and carbon monoxide detectors were operational. First aid kit inspected and observed complete with manual.

LPA obtained copies of updated LIC500 Personnel Report and LIC610D on this same day.

No deficiency observed.

Exit interview conducted and copy of this report provided to Charlie Olivar.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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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