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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200228
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:42:13 PM

Document Has Been Signed on 11/03/2022 02:42 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HENRY AND HENRY ADULT DAY CAREFACILITY NUMBER:
019200228
ADMINISTRATOR:ALLEN HENRYFACILITY TYPE:
775
ADDRESS:3361 MACARTHUR BLVD.TELEPHONE:
(510) 530-9656
CITY:OAKLANDSTATE: CAZIP CODE:
94602
CAPACITY: 30CENSUS: 17DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Allen Henry, AdministratorTIME COMPLETED:
03:00 PM
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On 11/3/2022 starting at 1:15 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator and disclosed the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bathrooms, common areas, and kitchen. There is one central entry point for universal screening for staff, residents and visitors. Facility has sufficient PPE supplies and are easily accessible for staff. Facility has Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors.

No deficiency cited during visit. Exit interview conducted with Administrator, and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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