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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200655
Report Date: 11/09/2021
Date Signed: 11/09/2021 12:16:09 PM

Document Has Been Signed on 11/09/2021 12:16 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,
, CA
FACILITY NAME:ALOHA RESIDENTIAL CARE INCFACILITY NUMBER:
019200655
ADMINISTRATOR:KATELYN SALVADORFACILITY TYPE:
735
ADDRESS:34706 WILLIAMS WAYTELEPHONE:
(510) 921-4949
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Katelyn Salvador, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tobola arrived unannounced to conduct a Required - 1 Year inspection and met with Administrator, Katelyn Salvador (KS). The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. There are 6 clients in care, 2 of which were at Day Program at the time of visit.

LPA toured facility and grounds with Administrator and observed COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Staff follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test within 72 hours. Staff clean and disinfect the facility per shift change. Administrator stated high touched surface areas are disinfected after each use, such as the bathroom and kitchen area. Client rooms and common areas have disinfecting wipes and hand sanitizer. Bathrooms are equipped with liquid soap, paper towels and garbage cans with touch less lids. Staff understand hand sanitizer should not be placed in the rooms of clients who lack hazard awareness and impulse control. Facility submitted a mitigation program plan, and plan has been reviewed. Caregivers have completed PPE training however, Administrator to schedule N-95 Mask Fit Testing Training for all staff.

In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. No accessible bodies of water or fire safety hazards observed. Fire Extinguishers were found to be charged and serviced 10/9/2021. Smoke and Carbon monoxide detectors were tested and fully operational.
There was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit.
Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ALOHA RESIDENTIAL CARE INC
FACILITY NUMBER: 019200655
VISIT DATE: 11/09/2021
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Advisory reports LIC9102 was given to facility regarding the following:
Administrator to schedule N95 Mask Fit Testing for all staff and submit testing schedule date by COB 11/12/2021.

LPA requested the following updated documents to be submitted to CCLD by 11/12/2021:
  • LIC500 Personnel Report
  • LIC308 Designation of Administrative Responsibility
  • LIC610 Emergency Disaster Plan
  • Liability Insurance

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
Due to printer malfunction, this report was emailed to Administrator.

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
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