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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200404
Report Date: 08/22/2022
Date Signed: 08/22/2022 11:01:29 AM

Document Has Been Signed on 08/22/2022 11:01 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CNS COURTYARDFACILITY NUMBER:
019200404
ADMINISTRATOR:STACEY MAGDEFRAUFACILITY TYPE:
735
ADDRESS:1465 - 65TH STREET, #112TELEPHONE:
(925) 719-5580
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY: 2CENSUS: 1DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Stacey Magdefrau, AdministratorTIME COMPLETED:
11:10 AM
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On 8/22/2022 starting at 9:30 a.m., Licensing Program Analysts (LPAs) C. Lin and L. Fici arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator Stacey Magdefrau and staff Alexandra Roscoe, and disclosed the purpose of the visit.

Upon entry, LPAs were asked Covid-19 symptoms questions and requested to wash hands by staff. LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, and common areas. There is one central entry point for universal screening for staff, residents, and visitors. Hand sanitizer, Cough/sneeze etiquette and hand washing posters were observed at facility. Facility staff were observed to be wearing proper PPE.

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 staff, and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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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