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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200191
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:03:47 PM

Document Has Been Signed on 05/05/2023 02:03 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:CEDAR HOME AT NILES GROVEFACILITY NUMBER:
019200191
ADMINISTRATOR:TRAN, MONIQUE NFACILITY TYPE:
735
ADDRESS:35525 NILES BLVD.TELEPHONE:
(510) 818-0716
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 6DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:EDITH SARMIENTO, Administrator TIME COMPLETED:
02:15 PM
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On 5/5/2023 starting at 9:41 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Edith Sarmiento and Monique N, Tran, Administrators (ADM) and explained the purpose of the visit. Administrator certificate for Edith Sarmiento expires on 6/12/2023 and certificate for Monique N, Tran expires on 5/16/2023. The facility’s fire clearance is approved for six (6) non-ambulatory. Upon entry, LPA observed four (4) staff and one (1) client present during inspection.

Starting at 10:37 AM, LPA toured facility with care staff including but not limited to six (6) bedrooms, two (4) bathrooms, kitchen, and common area. The facility consists of 6 total bedrooms which 6 bedrooms are private. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in clients’ common area bathroom was measured at 119.7 Degrees Fahrenheit. Clients’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Sharps and toxins were locked and inaccessible to clients'.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 10-18-2022. First aid kit was observed to be complete.


Continue on Lic809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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: CEDAR HOME AT NILES GROVE
FACILITY NUMBER: 019200191
VISIT DATE: 05/05/2023
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Continued from Lic809

Starting At 11:22 AM, LPA reviewed 4 of 4 staff records. At 11:57 AM, LPA reviewed 1 of 1 clients' records. At 12:14 PM, LPA reviewed one (1) client's medication.

Continued from Lic809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/12/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan (9 Pages)
· Liability Insurance
· Surety bond

No deficiencies cited during visit.








Exit interview conducted with care staff and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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