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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200507
Report Date: 05/11/2022
Date Signed: 06/06/2022 08:50:19 AM

Document Has Been Signed on 06/06/2022 08:50 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:SUTRO HOMEFACILITY NUMBER:
019200507
ADMINISTRATOR:DOREEN KHANFACILITY TYPE:
735
ADDRESS:22964 SUTRO STREETTELEPHONE:
(510) 728-5113
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 3DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Doreen Khan/AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA was granted entry by staff, Nabeel Arafat. Doreen Khan, administrator, arrived after several minutes. LPA also met with other staff, Satnam Kaur. LPA informed the purpose of visit.

Facility has LIC808 Mitigation Plan on file.

LPA toured the facility inside out with Doreen Khan and Nabeel Arafat. LPA inspected the living room, dining area, kitchen, bathrooms, bedrooms, laundry room, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, surgical masks and no touch temperature probe. Visitor's temperature and symptom checks are done at entry and recorded. Residents and staff are screened for COVID-19 symptoms and temperature checked daily and recorded/ Supplies of PPEs checked and observed adequate for 30 days for staff. All trash bins were observed with foot operated pedal lids. Antigen test kits are readily available. COVID-19 signages were posted in prominent areas in the facility.

Fire extinguisher checked and observed fully, and receipt showed purchased April 5. 2022. First aid kit was observed complete with manual. Hot water temperature in one of the bathrooms tested and measured at 108.4 degrees Fahrenheit.


.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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: SUTRO HOME
FACILITY NUMBER: 019200507
VISIT DATE: 05/11/2022
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Staff were fit tested for N95 respirators last year, and administrator stated she'll have all staff re-tested. Copy of fit testing record with the following information to be submitted by May 25, 2022:
  • Name and address of facility
  • Date, and name amd signature of person who conducted fit testing
  • Names of staff who were fit tested and signature
  • Fit test medium (eg: saccharin; smoke irritant)
  • N95 respirator model, make, size (eg: BYD, 3M; size; small, med, large) that fits the staff
  • Pass or fail information
  • Comments (if any)

Administrator to submit updated copies of the following documents by May 25, 2022:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan
4. Proof of Surety Bond coverage

No deficiency cited during today's visit.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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