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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200515
Report Date: 06/11/2021
Date Signed: 06/11/2021 02:25:56 PM

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:ABIGAIL'S GUEST HOMEFACILITY NUMBER:
019200515
ADMINISTRATOR:AURELIA MENDOZAFACILITY TYPE:
740
ADDRESS:6372 ARLINGTON DRIVETELEPHONE:
(925) 216-2921
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:6CENSUS: 5DATE:
06/11/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Carlota Moises, CaregiverTIME COMPLETED:
02:40 PM
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On 6/11/2021 at 1:30PM, Licensing Program Analyst (LPA) G. Luk conducted an unannounced Health & Safety inspection as a result of a priority 2 complaint. LPA met with caregiver, Carlota Moises. LPA spoke with administrator, Aurelia Mendoza and was informed that she is unable come to the facility.

LPA toured facility including but not limited to the bedrooms, bathrooms, dining area, living room, kitchen, and outdoor area. Hot water temperature was measured at 106.9 degrees F in the kitchen sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in kitchen cabinet. Smoke and carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 8/3/2020. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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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