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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200347
Report Date: 05/26/2023
Date Signed: 05/26/2023 02:44:08 PM

Document Has Been Signed on 05/26/2023 02:44 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: 48DATE:
05/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:FERDYLIN AMSDEN, Case Manager And BETCHIE TERRADO, Administrator.TIME COMPLETED:
02:55 PM
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On 5/26/2023 starting at 9:45 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met and was greeted by Ferdylin Amsden, Case manager, (CM) and Betchie Terrado, Administrator (ADM) and explained the purpose of the visit. The facility’s fire clearance was approved for all forty-one (41) ambulatory clients, and four (4) non-ambulatory clients.

Starting at 10:50 AM, LPA toured facility with ADM including but not limited to two (2) bathrooms, kitchen, and common area. The facility consists of five (5) rooms. All outdoor and indoor passageways are kept free of obstruction.There are no bodies of water observed. A comfortable temperature is maintained at 72 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in clients’ common area bathroom was measured at 107.0 Degrees Fahrenheit. Sharps and toxins were locked and inaccessible to clients' in care.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 9/16/2022. First aid kit was observed to be complete.

Starting At 12:15 PM, LPA reviewed 5 of 5 staff records. At 12:36 PM, LPA reviewed 5 of 5 clients' record which are current. At 1:40 PM, LPA reviewed a sample of 3 of 3 clients' medications.


Continue on Lic809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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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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: 05/26/2023
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Continued From Lic809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 6/2/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan (9 Pages)
· Liability Insurance



No deficiencies cited during visit.













Exit interview conducted with with ADM, and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
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