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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200205
Report Date: 06/20/2024
Date Signed: 06/21/2024 08:06:25 AM

Document Has Been Signed on 06/21/2024 08:06 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HANSEN HOMEFACILITY NUMBER:
019200205
ADMINISTRATOR/
DIRECTOR:
JESUSA MANTARINGFACILITY TYPE:
735
ADDRESS:7421 HANSEN DRIVETELEPHONE:
(510) 938-3661
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Jesusa MantaringTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 6/20/2024 at 9:05 AM, Licensing program Analyst Ardalan Gharachorloo and LPM Yvonne Flores-Larios arrived announced to conduct 1 year annual inspection. LPA met with facility staff explained the purpose of the visit. Administrators Jesusa Mantaring and Orlando Fajardo arrived shortly thereafter.

LPA and LPM toured the facility including but not limited to bedrooms, bathroom, kitchen, common area and backyard. All indoor and outdoor passageways are free of obstruction. There is an fenced in empty pool with locked gate that is inaccessible to clients in care. A comfortable temperature for the clients is maintained at 71 F. LPA observed lighting in all rooms and adequate for the comfort and safety of the clients. Hot water temperature in clients shared bathroom was measured at 105 degree F. All toilet, hand washing and bathing are safe,sanitary and in operating condition. The supply of extra hygienes was available for the clients. There is a minimum of 1 week supply of Non perishable and 2 days of perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during the visit. Fire extinguisher was last serviced on 02/10/2024. Emergency disaster plan was last posted on 08/10/2023. First aid kit was observed to be complete. Fire drill was last conducted on 06/17/2024.

LPA reviewed 6 clients records and 5 staff records and all were complete. All clients medications were reviewed.

No deficiencies were cited during this inspection. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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