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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200346
Report Date: 01/06/2023
Date Signed: 01/06/2023 01:52:17 PM

Document Has Been Signed on 01/06/2023 01:52 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CALLAHAN HOMEFACILITY NUMBER:
019200346
ADMINISTRATOR:GAIL CALLAHANFACILITY TYPE:
735
ADDRESS:658 VALLE VISTA AVENUETELEPHONE:
(510) 832-4258
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 12CENSUS: 8DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Amanda Callahan, AdministratorTIME COMPLETED:
02:00 PM
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On 1/6/2023 starting at 12:50 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with the Administrator and disclosed the purpose of the visit.

Upon entry, LPA was requested to sign in and wash hands. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, common areas, and outdoor areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed.

Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, 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: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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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