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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200281
Report Date: 06/06/2022
Date Signed: 06/06/2022 03:20:40 PM

Document Has Been Signed on 06/06/2022 03:20 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:DICHONDRA PLACEFACILITY NUMBER:
019200281
ADMINISTRATOR:LEEA BURNSFACILITY TYPE:
735
ADDRESS:5772 DICHONDRA PLACETELEPHONE:
(510) 894-1413
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 3CENSUS: 3DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Humphrey Kasweka, CaregiverTIME COMPLETED:
03:25 PM
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On 6/6/2022 at 2:25 PM, Licensing Program Analysts (LPAs) L. Hall and L. Fici arrived unannounced to conduct an Infection Control Inspection. LPAs met with Humphrey Kasweka, Caregiver, and explained the purpose of the visit. Administrator, Leea Burns arrived 2:50PM.

Upon entry, LPAs' temperature was checked and screening station was observed. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. LPAs observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing poster. Hot water temperature in the shared clients’ bathroom was measured at 106.6 degrees Fahrenheit. Fire extinguisher was last serviced on 12/6/2021.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, paper supplies, and food are sufficient.

The following forms are to be updated and submitted to CCLD by 6/13/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DICHONDRA PLACE
FACILITY NUMBER: 019200281
VISIT DATE: 06/06/2022
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Continued from LIC809.

-LIC610D Emergency Disaster Plan

No deficiencies were observed during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
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