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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201193
Report Date: 12/06/2024
Date Signed: 12/06/2024 12:03:22 PM

Document Has Been Signed on 12/06/2024 12:03 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:RACHELL'S FACILITYFACILITY NUMBER:
019201193
ADMINISTRATOR/
DIRECTOR:		EVANS, RACHELLFACILITY TYPE:
735
ADDRESS:33103 8TH STREETTELEPHONE:
(510) 331-2598
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 2DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Natisha Evans, Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 12/06/2024 at 10:40 AM, Licensing Program Analysts (LPAs) Luisa Fontanilla and Patricia Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Direct Support Staff (DSP), Natisha Evans and explained the purpose of the visit. Evans phoned the House Manager Mirzett Evans and received verbal consent to sign the report today.

LPAs toured the facility with Natisha Evans including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which all bedrooms are occupied by the clients. There are no bodies of water. A comfortable temperature for the clients is maintained at 79 degree Fahrenheit. LPAs 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 113.4 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's and linen was available for clients. Cabinet for knives and centrally storage for medication were observed locked. Outdoor activity space was observed furnished with tables, chairs and shade.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/03/2024. First aid kit was observed to be complete. Fire Drill was last conducted on 11/14/2024.

At 10:51 AM, 3 staff records were reviewed and 3 of 3 have current first aid training and 3 of 3 associated to the facility. At 11:05 AM, 3 of clients records were reviewed. LPAs reviewed client's P&I money with log and there was no discrepancies observed. LPAs reviewed samples of client's medications. All records were observed to be complete and up to date.

Continue to LIC809C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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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: RACHELL'S FACILITY
FACILITY NUMBER: 019201193
VISIT DATE: 12/06/2024
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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/13/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan
Liability Insurance
Auto Insurance/Registration/Driver's License

No deficiencies found during the visit. A copy of this report is provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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