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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200540
Report Date: 03/03/2022
Date Signed: 03/03/2022 04:15:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/03/2022 04:15 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:NOBLE HEARTS CARE HOMEFACILITY NUMBER:
019200540
ADMINISTRATOR:SHARONDALYN CONNERFACILITY TYPE:
735
ADDRESS:846 37TH STREETTELEPHONE:
(510) 250-9410
CITY:OAKLANDSTATE: CAZIP CODE:
94608
CAPACITY: 5CENSUS: 2DATE:
03/03/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Sharondalyn Conner, AdministratorTIME COMPLETED:
04:30 PM
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On 3/3/2022 started at 3:25 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection continuation. LPA met with Administrator Sharondalyn Conner and explained the purpose of the visit.

Upon entry, LPA’s temperature was checked and asked Covid-19 questions at the front door. LPA toured facility including but not limited to front entrance, screening station, bedrooms, bathrooms, kitchen and common areas. 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. Facility staff were observed to be wearing proper PPE.

Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan and Emergency Disaster Plan on file.

No deficiency cited during visit. Exit interview conducted with Administrator, and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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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