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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200234
Report Date: 04/09/2024
Date Signed: 04/09/2024 09:49:25 AM

Document Has Been Signed on 04/09/2024 09:49 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:PEACE HOMEFACILITY NUMBER:
019200234
ADMINISTRATOR/
DIRECTOR:
CHRISTOPHER IBHAWOFACILITY TYPE:
735
ADDRESS:2076 STRANG AVENUETELEPHONE:
(510) 278-8350
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 3CENSUS: 3DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:44 AM
MET WITH:Caregiver, Michael Jones TIME VISIT/
INSPECTION COMPLETED:
09:55 AM
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On 4/09/2024 at 7:15 AM, Licensing Program Analysts (LPAs) A. Gomez and A Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Michael Jones and explained the purpose of the visit. Administrator, Christopher IBHAWO arrived at approximately 8:42 AM The facility’s fire clearance was approved for 3 Ambulatory. All residents were at Day Program

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which 3 bedrooms are occupied by the clients and 0 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 108.2 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygienes were available for clients. There is a minimum of one week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 2/15/2023. LPA advised administrator that fire extinguisher needs an update. Emergency Disaster plan was last posted on 12/10/2023. First aid kit was observed to be complete. Fire drill was last conducted on 1/13/2024.

At 8:00AM, 3 of clients records were reviewed. LPA advised administrator to get LIC627C filled out in residents files. At 8:30AM, 3 staff records were reviewed and 3 of 3 have current first aid training and associated to the facility. Surety bond covers the P&I amount.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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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