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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200311
Report Date: 12/02/2021
Date Signed: 12/02/2021 02:52:32 PM

Document Has Been Signed on 12/02/2021 02:52 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:THOMAS-ADAMS RESIDENTIAL CARE FACILITY, INC.FACILITY NUMBER:
019200311
ADMINISTRATOR:HAROLD THOMASFACILITY TYPE:
735
ADDRESS:5152-5158 FOOTHILL BLVD.TELEPHONE:
(510) 533-3470
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY: 32CENSUS: 31DATE:
12/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Matthew Thomas, Administrator TIME COMPLETED:
03:15 PM
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On 12/2/2021 aT 12:45 PM, Licensing Program Analyst (LPAs) G. Clark and L. Francisco arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Matthew Thomas 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, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. 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.

No deficiencies cited during visit. Exit interview conducted and due to technical issues and a copy of this report provided via email.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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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