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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200900
Report Date: 05/21/2024
Date Signed: 05/21/2024 01:27:52 PM

Document Has Been Signed on 05/21/2024 01:27 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:AMADORFACILITY NUMBER:
019200900
ADMINISTRATOR/
DIRECTOR:		TANYA M BARRETOFACILITY TYPE:
735
ADDRESS:7137 AMADOR VALLEY BLVDTELEPHONE:
(925) 248-2148
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 4CENSUS: 3DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Ramon Romo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On 5/21/2024 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA rang the doorbell and knock on the door multiple times without response. LPA spoke with former Administrator, Tanya Barreto who provided current Administrator's phone number. LPA spoke with current Administrator, Ramon Romo who arrived 20 minutes later. The facility’s fire clearance was approved for 4 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide combination detectors were observed in operating condition. Fire extinguishers were observed to be full and last serviced on 11/3/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 109.6 degrees F in the hallway bathroom. There were adequate lights in each room. First Aid kit is complete. No bodies of water observed. Indoor and outdoor passageways were free of obstruction.

LPA reviewed 3 clients and 4 staff files starting at 10:45AM. LPA reviewed client's P&I money and log. LPA reviewed a sample of client's medications during inspection. Clients were in day program during inspection and unable to interview clients. LPA interview staff at around 12:50PM.

At 11:30AM, LPA observed S3 does not have current first aid training on file during record review.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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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Document Has Been Signed on 05/21/2024 01:27 PM - It Cannot Be Edited


Created By: Grace Luk On 05/21/2024 at 01:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMADOR
FACILITY NUMBER: 019200900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current first aid training for S3 which poses a potential health and safety risk to persons in care.
POC Due Date: 06/11/2024
Plan of Correction
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Administrator has agreed to obtain current first aid training for S3 and submit a copy of completion certificate to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
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