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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200905
Report Date: 07/01/2024
Date Signed: 07/01/2024 01:56:26 PM

Document Has Been Signed on 07/01/2024 01:56 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:NATIONAL PHOENIXFACILITY NUMBER:
019200905
ADMINISTRATOR/
DIRECTOR:		PINTO, OLGAFACILITY TYPE:
772
ADDRESS:740 HOLLYHOCK DRIVETELEPHONE:
(408) 688-4737
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 6CENSUS: 2DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Kimberly Saleang, Mental Health StaffTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 07/01/2024 at 11:20 AM, Licensing Program Analyst (LPA)Tonica Syess-Gibson conducted an unannounced annual required inspection. LPA met with Kimberly Saleang and explained the purpose of the visit. Maira Herrera contacted the Program Director via telephone to advise of visit. Program Director, Olga Pinto , arrived at approximately 11:55 AM. LPA toured the facility with Maira Herrera, Nurse Program Manager and Program Director, Olga Pinot. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) total bedrooms and four (4) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degrees 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 106.6 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.


Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 07/30/2024 Emergency Disaster Plan was last posted on 02/08/2024. First aid kit was observed to be complete. Fire drill was last conducted on 06/21/2024.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NATIONAL PHOENIX
FACILITY NUMBER: 019200905
VISIT DATE: 07/01/2024
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Continued from LIC809.

Three (3) staff records reviewed and complete. All Two (2) clients records reviewed, current, and complete. LPA reviewed Facility transportation vehicle document: Department of Motor Vehicle Registration, Service invoices for tires and oil changes.

The following forms to be updated and submitted to CCLD by 07/08/2024:

· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC308 Designation of facility responsibility
· LIC 500 Personnel Report
· LIC610D Emergency Disaster Plan

No deficiencies observed during this visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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