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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200403
Report Date: 12/30/2021
Date Signed: 12/30/2021 10:02:09 AM

Document Has Been Signed on 12/30/2021 10:02 AM - 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:FAYETH'S DOORFACILITY NUMBER:
019200403
ADMINISTRATOR:PAMELA BROWNFACILITY TYPE:
735
ADDRESS:1801 VIA BARRETTTELEPHONE:
(510) 385-8463
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY: 6CENSUS: 5DATE:
12/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lashana West, DSPTIME COMPLETED:
10:10 AM
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On 12/30.21 at 9 AM Licensing Program Analyst (LPA) G. Clark and LPM Yvonne Flores-Larios arrived unannounced to conduct Infection Control Inspection. LPA and LPM met with staff Lashana West and Administrator Pamela Brown by phone and explained the purpose of the visit.

During the Infection Control Inspection, LPA and LPM toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. 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, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were reminded to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility will send mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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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