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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200510
Report Date: 08/26/2021
Date Signed: 08/26/2021 12:59:33 PM

Document Has Been Signed on 08/26/2021 12:59 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:CNS COURTYARD #122FACILITY NUMBER:
019200510
ADMINISTRATOR:STACEY MAGDEFRAUFACILITY TYPE:
735
ADDRESS:1465 65TH STREET, #122TELEPHONE:
(925) 719-5580
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY: 2CENSUS: 1DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Stacey Magdefrau, AdministratorTIME COMPLETED:
01:20 PM
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On 8/26/2021 starting at 9:35 AM, Licensing Program Analysts (LPAs) L. Francisco and C. Lin arrived unannounced to conduct Infection Control Inspection. Administrator, Stacey Magdefrau later arrived at 10:30am.

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

No deficiency cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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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