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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200507
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:33:08 PM

Document Has Been Signed on 05/04/2023 03:33 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:SUTRO HOMEFACILITY NUMBER:
019200507
ADMINISTRATOR:DOREEN KHANFACILITY TYPE:
735
ADDRESS:22964 SUTRO STREETTELEPHONE:
(510) 728-5113
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 4DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mohammed Arafat/Licensee and
Doreen Khan/Administrator		TIME COMPLETED:
03:35 PM
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On this day, May 4, 2023, at 10:45 a.m, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by Mohammed Arafat, licensee, and informed the reason for visit. LPA called and spoke over the phone with Doreen Khan, licensee- administrator, who indicated she's with 2 of the residents for appointments. The administrator arrived at around 11:50 am after dropping off the residents to their day program.

Facility has an approved LIC808 Mitigation Plan, and on facility file, an LIC9282 Infection Control Plan; however, copy of LIC9282 has not been submitted to the Department.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, laundry room, kitchen, dining and living rooms. front and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguisher was observed fully chargem and receipt showed purchased on May 3, 2023. Facility has carbon monoxide and 2 in 1 smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in the common bathroom was tested and measured at 107 degrees Fahrenheit. Facility conducts disaster drills monthly, and records showed last conducted April 19, 2023. Cabinets were sharps and medications are kept were observed locked.

LPA reviewed 4 residents and 4 staff files, and interviewed 2 staff and 2 residents. Medications were checked and compared with records. Residents' cash resources match the records.


.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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: SUTRO HOME
FACILITY NUMBER: 019200507
VISIT DATE: 05/04/2023
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The following updated documents to be submitted by May 18. 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. LIC9282 Infection Control Plan
5. Proof of Surety Bond coverage

No deficiency cited.

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

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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