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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200158
Report Date: 01/31/2024
Date Signed: 01/31/2024 02:52:04 PM

Document Has Been Signed on 01/31/2024 02:52 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: 21DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Charlie Olivar/Program DirectorTIME COMPLETED:
02:55 PM
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On this day, 1/31/24, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Program Director (PD) Charlie Olivar, and informed the reason for visit..

LPA toured the facility inside out with PD. The facility has two buildings, one in front and one at the back. LPA inspected both buildings. LPA inspected the common areas, relaxation/quiet room. conference/case management room. toilets, arts and crafts and activity areas. Storage for cleaning supplies and disinfectants were observed locked.

There are activity areas in both buildings which were observed free of hazard and obstructions. Clients are provided snacks and they bring their own lunch. LPA observed sufficient supplies of snacks. Kitchen and food preparation areas were observed clean.

Facility has working 2 in 1 carbon monoxide and smoke detector.. Fire extinguisher checked, observed fully charge, and tag showed serviced December 13, 2023. Facility conducts disaster drills monthly, and records showed last conducted 1/29/24. Water temperature in one of the toilets was tested and measured at 108.9 degrees Fahrenheit.


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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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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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: MISSION HOPE DAY PROGRAM- HAYWARD
FACILITY NUMBER: 019200158
VISIT DATE: 01/31/2024
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LPA reviewed 5 staff and 5 client files, and interviewed 1 staff and 2 clients. Facility does not handle clients money.

LPA received the following current documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. LIC9283 Infection Control Plan

No deficiency cited.

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

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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