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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200395
Report Date: 01/28/2023
Date Signed: 01/28/2023 12:27:46 PM

Document Has Been Signed on 01/28/2023 12:27 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:PECO CARE HOMEFACILITY NUMBER:
019200395
ADMINISTRATOR:JEAN B. RODRIGUEZFACILITY TYPE:
735
ADDRESS:34914 PECO STREETTELEPHONE:
(510) 386-4912
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
01/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Jean Rodriguez, AdministratorTIME COMPLETED:
12:35 PM
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On 01/28/2023 at 11::50AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Jean Rodriguez, Administrator and explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station and mask sign on front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 110.3 degrees Fahrenheit. Fire extinguisher last serviced on 5/17/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke/carbon monoxide detector operable.

During record review, LPA observed facility has a copy of the Mitigation plan on file. LPA observed PPE and paper supplies are sufficient.

No deficiencies cited during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2023
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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