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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200766
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:58:30 PM

Document Has Been Signed on 01/07/2025 03:58 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:QUEEN CARE HOMEFACILITY NUMBER:
019200766
ADMINISTRATOR/
DIRECTOR:		PITSCHNER, MARIANFACILITY TYPE:
735
ADDRESS:22090 QUEEN STREETTELEPHONE:
(510) 584-6922
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 6CENSUS: 6DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Administrator, Zhe LiTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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On 01/07/2024 at 12:25 PM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Zhei Li and explained the purpose of the visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 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 108-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 and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/23/2024. Emergency Disaster Plan was last posted on 01/04/2024. First aid kit was observed to be complete. Fire drill was last conducted on 12/04/2024.

LPA reviewed 5 clients’ records and 5 staff records, and all were complete. A sample of 3 client’s medications were reviewed. LPA reviewed the following documents during the visit:LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility, LIC 400 Affidavit Regarding Client/Resident Cash Resources, LIC 402 Surety Bond, LIC 610D 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: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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