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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200766
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:01:30 PM

Document Has Been Signed on 04/25/2022 03:01 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:QUEEN CARE HOMEFACILITY NUMBER:
019200766
ADMINISTRATOR:PITSCHNER, MARIANFACILITY TYPE:
735
ADDRESS:22090 QUEEN STREETTELEPHONE:
(510) 584-6922
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 6CENSUS: 6DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Marian Pitschner, AdministratorTIME COMPLETED:
03:10 PM
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On 4/25/22 at 1:50pm, Licensing Program Analysts (LPAs) K. Nguyen and, L. Francisco arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPAs were greeted by Care Staff, Mavic Ramos. Administrator, Marian Pitschner later arrived at 2:45 PM.

During the Infection Control Inspection, LPAs toured facility with Mavic Ramos, Lead staff including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. 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, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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