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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200795
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:18:48 PM


Document Has Been Signed on 01/26/2023 03:18 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:HOLISTIC CARE HOMEFACILITY NUMBER:
019200795
ADMINISTRATOR:NGUYEN, AYWON-ANHFACILITY TYPE:
740
ADDRESS:14724 PEPPERDINE STTELEPHONE:
(510) 969-7966
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY:6CENSUS: 6DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Jacqueline Adams, AdministratorTIME COMPLETED:
03:30 PM
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On 1/26/2023 at 1:55 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Administrator, Jacqueline Adams and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility with Jacqueline including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient two day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. 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 bins. Facility staff were observed to be wearing proper PPE. Facility has a 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. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. Fire extinguisher was observed serviced. LPA observed facility passages inside and out free of obstruction.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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