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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200750
Report Date: 06/10/2022
Date Signed: 06/10/2022 06:02:57 PM


Document Has Been Signed on 06/10/2022 06:02 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:SCOTT VILLAFACILITY NUMBER:
019200750
ADMINISTRATOR:JONABELLE TOLENTINOFACILITY TYPE:
740
ADDRESS:1560 MIDDLE LANETELEPHONE:
(510) 782-7833
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:35CENSUS: 35DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Jonabelle Tolentino/AdministratorTIME COMPLETED:
06:05 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with Jonabelle Tolentino, administrator, and informed the purpose of visit.

Facility has an approved LIC808 Mitigation Plan on file.

LPA toured the facility inside out with Jonabelle Tolentino. LPA inspected the living room, dining area, kitchen, hallways, side and backyard. LPA randomly selected 9 bedrooms for inspection. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe and Visitor's Log. Visitor's temperature and symptom checks are done at entrance. Residents and staff are screened for COVID-19 symptoms, and temperature checked and recorded daily. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs were checked and observed adequate for 30 days, and antigen test kits are readily available. Staff were fit tested for N95 respirator, and copy of record was requested by LPA which LPA received on May 12, 2022.

Fire extinguishers checked and observed fully charge with tags showed serviced January 19, 2022. Hot water temperature in one of the common bathrooms was tested and measured at 112.6 degrees Fahrenheit.

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SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SCOTT VILLA
FACILITY NUMBER: 019200750
VISIT DATE: 06/10/2022
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Administrator to submit copies of the following updated documents by June 24, 2022:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan
4. Proof of $3M liability insurance.

LPA reminded that new Infection Control Plan should be submitted by June 30. 2022.

No deficiency cited during today's visit.

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: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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