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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200724
Report Date: 07/06/2022
Date Signed: 07/06/2022 12:32:46 PM


Document Has Been Signed on 07/06/2022 12:32 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:GRAND LAKE HOMEFACILITY NUMBER:
019200724
ADMINISTRATOR:THERESA BENIGNOFACILITY TYPE:
740
ADDRESS:365 STATEN AVENUETELEPHONE:
(510) 836-7549
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:14CENSUS: 12DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Theresa Benigno, AdministratorTIME COMPLETED:
12:45 PM
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On 7/6/2022 starting at 10:45 a.m., Licensing Program Analysts (LPAs) C. Lin and L. Fici arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator Theresa Benigno and disclosed the purpose of the visit.

Upon entry, LPAs’ temperature was checked by the staff. LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, common areas, and outdoor 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. Cough/sneeze etiquette and hand washing posters were observed. 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, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors.

No deficiency cited during visit. Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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