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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200544
Report Date: 02/24/2022
Date Signed: 02/24/2022 06:12:07 PM


Document Has Been Signed on 02/24/2022 06:12 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:AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
019200544
ADMINISTRATOR:ALBERT LEANOFACILITY TYPE:
740
ADDRESS:23652 NEVADA ROADTELEPHONE:
(510) 314-0807
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
05:45 PM
MET WITH:Albert Leano/Administrator and
Leticia 'Lettie' Velasco/Staff		TIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Delmundo conducted Proof of Correction visit. LPA met with Albert Leano, administrator, and Leticia 'Lettie' Velasco, staff.

LPA toured the facility with Leticia Velasco and observed the yard cleaned, LPA also observed the central storage for medications, staff room and cabinet for knives, and cabinets in the garage where cleaning supplies are kept were locked. Administrator submitted copies of in-service training on February 16, 2022.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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