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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200331
Report Date: 10/27/2022
Date Signed: 02/21/2023 12:06:50 PM

Document Has Been Signed on 02/21/2023 12:06 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:COVENTRY CARE HOMEFACILITY NUMBER:
019200331
ADMINISTRATOR:MARIDEL Q. CORTEZFACILITY TYPE:
735
ADDRESS:4284 COVENTRY WAYTELEPHONE:
(510) 972-0861
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Ricardo Cortez, LicenseeTIME COMPLETED:
01:50 PM
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On 10/27/2022, at 12:40 PM, Licensing Program Analyst (LPA) Liridon Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by Care Staff, at front door entrance. At 12:56 PM, Ricardo Cortez, Licensee arrived and met with LPA.

During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All sharps and toxins were locked up and inaccessible to clients in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 116.6 degrees F. Fire extinguisher was last serviced on 12/2/2021. Facilities room temperature is maintained at 70 Degrees F. First aid kit is complete. Carbon monoxide and smoke detector are operable. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care.

No deficiencies cited during today's visit.

Exit interview conducted with Licensee and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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