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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200347
Report Date: 06/20/2022
Date Signed: 06/20/2022 03:05:09 PM

Document Has Been Signed on 06/20/2022 03:05 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:MISSION HOPE DAY PROGRAM, FREMONTFACILITY NUMBER:
019200347
ADMINISTRATOR:BETCHIE TERRADOFACILITY TYPE:
775
ADDRESS:43154 OSGOOD ROADTELEPHONE:
(510) 226-1600
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 45CENSUS: 18DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Ferdylin Amsden- Case ManagerTIME COMPLETED:
03:10 PM
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On 06/20/2022 at 2:13pm, Licensing Program Analysts (LPAs) L. Fici & L. Ibo arrived unannounced to conduct an annual Infection Control Inspection. LPAs met with Case manager, Ferdylin and explained the purpose of the visit.

LPAs toured facility with Ferdylin including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, and kitchen. Facility has a sufficient 2-day perishables. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, Covid questionnaires, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. 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. First Aid kit was complete. Fire extinguisher was observed serviced September 2021 . LPAs observed facility passages inside and out free of obstruction.

Continue on LIC809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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: MISSION HOPE DAY PROGRAM, FREMONT
FACILITY NUMBER: 019200347
VISIT DATE: 06/20/2022
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Continued on LIC809C

The following forms are to be updated and submitted to CCLD By 6/27/2022.

- LIC500- Personnel Report
- LIC308- Designation of Administrative Responsibility
- LIC610E- Emergency Disaster Plan

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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