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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200218
Report Date: 09/30/2022
Date Signed: 09/30/2022 11:05:44 AM

Document Has Been Signed on 09/30/2022 11:05 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MISSION-HOPE DAY PROGRAM, DUBLINFACILITY NUMBER:
019200218
ADMINISTRATOR:JAY FRANCIS Y. GAMEZFACILITY TYPE:
775
ADDRESS:6300 VILLAGE PARKWAYTELEPHONE:
(925) 560-9582
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 45CENSUS: 72DATE:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
11:15 AM
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On 9/30/22 at 9:30 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPA met with Program Director Maribeth Wilson and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, activities room, computer room, relaxing room, kitchen and backyard. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

During record review, LPAs reviewed a sample of 5 staff records and observed 5 of 5 have health screening with TB test on file.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/7/2022:

LIC 308 Designation of Administrative Responsibility

LIC 309 Administrative Organization

LIC 500 Personnel Report

LIC 610D Emergency Disaster Plan

Liability Insurance

Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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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