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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200890
Report Date: 09/22/2021
Date Signed: 09/22/2021 04:14:01 PM

Document Has Been Signed on 09/22/2021 04:14 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:CALANDRIA RESIDENTIAL CARE HOME INCFACILITY NUMBER:
019200890
ADMINISTRATOR:WAUGH, RONDIEFACILITY TYPE:
735
ADDRESS:2457 65TH AVENUETELEPHONE:
(510) 626-4911
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 6CENSUS: 5DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:WAUGH, RONDIETIME COMPLETED:
04:45 PM
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On 9/22/2021 at around 2:10 PM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with WAUGH, RONDIE. LPA observed 5 clients during the visit. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational. No bodies of water observed during the visit.



...Continued on next page LIC 809-C...

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CALANDRIA RESIDENTIAL CARE HOME INC
FACILITY NUMBER: 019200890
VISIT DATE: 09/22/2021
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LPA observed the following:

· Facility DOES NOT document daily COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility. LPA provided technical assistance; the facility was checking for temperature for staffs & residents but no documentation for covid19 symptoms. Proof of correction was requested to be submitted on or before 10/8/2021. ( no citation, technical assistance provided )

· Staff are not FIT tested for N95, LPA requested for proof of FIT testing for all staff to be sent on or before 10/8/2021. ( technical assistance provided )

No deficiency cited during the visit.


Exit interview conducted with Adminsitrator and a copy of this report & appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC809 (FAS) - (06/04)
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