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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200212
Report Date: 12/08/2022
Date Signed: 12/08/2022 02:53:47 PM

Document Has Been Signed on 12/08/2022 02:53 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:BURNHAM PLACEFACILITY NUMBER:
019200212
ADMINISTRATOR:JOSEPHINE ABELLAFACILITY TYPE:
735
ADDRESS:22 BURNHAM PL.TELEPHONE:
(510) 793-1069
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 6CENSUS: 6DATE:
12/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Josephine Abella, AdministratorTIME COMPLETED:
03:00 PM
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On 12/8/22 at 2:30 p.m.. Licensing Program Analyst (LPA) Greg Clark conducted a Case Management visit as result of an uncleared person at the facility on a previous visit. LPA met with Administrator, Josephine Abella and explained the purpose of the visit. All staff present at the facility are associated and cleared.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 112.5 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Room temperature was observed at 70 degrees F. Resident's medications were kept locked in the med cabinet. Smoke detectors and carbon monoxide detectors were observed. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 1/21/22. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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