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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200658
Report Date: 01/03/2024
Date Signed: 01/03/2024 03:59:48 PM

Document Has Been Signed on 01/03/2024 03:59 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:EVELYN MANORFACILITY NUMBER:
019200658
ADMINISTRATOR:MONTECLAR, IRENEFACILITY TYPE:
735
ADDRESS:1076 TULANE AVETELEPHONE:
(510) 878-2352
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY: 4CENSUS: 4DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:TIME COMPLETED:
04:15 PM
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On 1/03/24 at 1:45 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Irene Monteclar and explained the purpose of the visit. The facility’s fire clearance was approved for 4.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 4 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70-degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 115.8-degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of one-week supply of non-perishables and 2-day perishables food supply.

Smoke detectors, carbon monoxide and fire extinguisher were in operating condition during visit. First aid kit was observed to be complete. Fire drill was last conducted on 12/20/23.

LPA reviewed 4 clients’ records and 4 staff records, and all were complete. A sample of 2 client’s medications were reviewed.

Updated copies of the following documens were requested for facility file and are to be submitted to CCL by 12/05/24: LIC 610E Emergency Disaster Plan

No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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