<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200705
Report Date: 07/22/2024
Date Signed: 07/22/2024 01:30:36 PM

Document Has Been Signed on 07/22/2024 01:30 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:FULTON CAREFACILITY NUMBER:
019200705
ADMINISTRATOR/
DIRECTOR:		OCAL, GLENFACILITY TYPE:
735
ADDRESS:29024 RUUS ROADTELEPHONE:
(510) 887-6026
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 14CENSUS: 14DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Theresa Abernathy, Care Staff TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/22/2024 at 10:00 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA was greeted by care staff, Theresa Abernathy. Care staff informed Administrator (AD) Glen Ocal. LPA spoke with AD and explained the purpose of the visit. LPA conducted the inspection process, later AD arrived. The facility’s fire clearance was approved for 14 ambulatory residents.

LPA toured facility with care staff Theresa including but not limited to front entrance, 8 bedrooms, 7 rooms is occupied with clients, and one is a staff room, common areas, kitchen, and backyard. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms of which 7 bedrooms are occupied by the clients and 1 bedroom is for staff. 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 118.9-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.

Fire drill was conducted on 10/17/2024. Fire extinguisher last check on 1/3/2024. Emergency plan was last posted on 7/21/2024. Facility has a current liability insurance from 8/1/2023-8/1/2024. LPA reviewed 2 staff record and two out of 2 have TB on file, also associated to the facility. LPA reviewed five resident files.


Exit interview conducted and a copy of this report provided via email.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1