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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201111
Report Date: 03/18/2022
Date Signed: 03/18/2022 11:45:39 AM

Document Has Been Signed on 03/18/2022 11:45 AM - 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:MILA'S HOMEFACILITY NUMBER:
019201111
ADMINISTRATOR:YAMBAO, JOAQUIN ALEJANDROFACILITY TYPE:
735
ADDRESS:968 FOLSOM AVETELEPHONE:
(925) 337-9199
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: DATE:
03/18/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:JOAQUIN ALEJANDROTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPAs) Jill Clancy-Czuleger and D. Fici, conducted an announced pre-licensing inspection. License application is for 4 total capacity, of which 0 maybe non-ambulatory. Fire clearance was granted on February 16,2022. LPAs met with Joaquin Alejandro (applicant-licensee).


LPAs inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPAs inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Outdoor activity space was observed furnished with tables, chairs and shade.

Fire extinguishers were observed fully charge. The two-in-one carbon monoxide and smoke detector tested and observed functional. Hot water temperature in one of the bathrooms tested and measured at 117.1 degrees Fahrenheit.

LPA conducted Component III with Licensee, Administrator, Administrator in training and Campus Director during Tele-visit. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.

Continued on 809-C




SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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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: MILA'S HOME
FACILITY NUMBER: 019201111
VISIT DATE: 03/18/2022
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No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. Exit interview conducted and a copy of this report will be emailed
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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