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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200507
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:30:10 PM

Document Has Been Signed on 04/12/2024 02:30 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/
DIRECTOR:		DOREEN KHANFACILITY TYPE:
735
ADDRESS:22964 SUTRO STREETTELEPHONE:
(510) 728-5113
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 4DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Mohammed Arafat/Licensee and
Doreen Khan/Administrator 		TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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At 10:15 am on this day, April 12, 2024, 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. Doreen Khan, administrator. arrived at around 10:50 a.m.

Administrator submitted a copy of updated LIC9282 Infection Control Plan which LPA received on May 5, 2023.

LPA toured the facility inside out with the licensee. LPA inspected the kitchen, dining area, living room. bedrooms, bathrooms, garage and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked.

Facility has 2 in 1 carbon monoxide and smoke detector that was tested, and observed functional. Facility conducts fire and earthquake drills at least every quarter and records showed last conducted March 17, 2024. Fire extinguisher checked, observed fully charge and receipt showed purchased May 3, 2023. Hot water temperature in the common bathroom was tested and measured at 107.2 degrees Fahrenheit.

LPA reviewed 3 staff and 4 residents records, and interviewed 2 staff. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. P&I were checked and compared with last recorded balance.

At 10:37 a.m., LPA observed the laundry room/office converted to resident's room

....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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: 04/12/2024
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Administrator to submit the following current/updated documents by April 26, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D, A $500 civil penalty is assessed on this day.

Deficiency and plan and proof of correction were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2024 02:30 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/12/2024 at 02:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SUTRO HOME
FACILITY NUMBER: 019200507

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in converted the laundry room/office to resident's bedroom which poses an immediate safety risk to persons in care.
POC Due Date: 04/06/2024
Plan of Correction
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Administrator submitted copies of facility sketches nd LIC9054 Local Inspection Authority Information while LPA was at the facility.
LPA to submit the sketches and STD850 Fire Safety Inspection Request to Fire Department.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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