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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201039
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:38:58 PM


Document Has Been Signed on 07/14/2022 03:38 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:CAREFIELD PLEASANTONFACILITY NUMBER:
019201039
ADMINISTRATOR:SINGH, PARVEENFACILITY TYPE:
740
ADDRESS:4115 MOHR AVE.TELEPHONE:
(925) 461-8409
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:82CENSUS: 40DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Parveen Singh, Senior Executive Director
Eunice O'Farrell, Assistant Executive Director		TIME COMPLETED:
03:55 PM
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On 7/14/2022 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Senior Executive Director, Parveen Singh and Assistant Executive Director, Eunice O'Farrell. LPA explained the purpose of the visit.

Upon entry, LPA's temperature was checked and asked to fill out COVID-19 questionnaire on the automated kiosk. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor area. LPA observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All bathrooms were equipped with soap and paper towel. Hand washing posters were posted at bathrooms.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPEs, food supplies, and paper supplies are sufficient.

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102.

No deficiencies were cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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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