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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201125
Report Date: 12/04/2024
Date Signed: 12/04/2024 01:18:13 PM

Document Has Been Signed on 12/04/2024 01:18 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:GLEN EDENFACILITY NUMBER:
019201125
ADMINISTRATOR/
DIRECTOR:		RAMAS, ELINOREFACILITY TYPE:
735
ADDRESS:238 ESTHER COURTTELEPHONE:
(510) 940-8382
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Fatima Lacsamana, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 12/04/2024 at 9:00 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1 year required annual. LPA met with Administrator, Maria Fatima Lacsamana and explained the purpose of the visit.

LPA toured the client’s bedrooms, bathrooms, common living areas, kitchen, garage and backyard. There are four (4) bedrooms, and three (3) bathrooms. There is sufficient lighting around the facility. Clients' rooms are equipped with the proper furniture, bedding and lighting. Hot water temperature is measured at 113.8 degrees Fahrenheit. LPA observed locked cabinets that store toxins and sharps and a locked mobile cart for medications. Required posters are posted on the wall. Thermometer in hallway showed temperature as 71 degrees F. Emergency disaster plan dated 01/01/2024. Fire drill last conducted 08/27/2024. Fire extinguisher was last serviced on 10/28/2024. First Aid kit was complete. Carbon monoxide/smoke detectors were in working condition. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. Fire extinguisher was observed serviced. LPA observed facility passages inside and out free of obstruction.

LPA reviewed 4 clients files and 2 staff record. 2 out of 2 staff record have TB and current CPR/First Aid on files.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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