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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201233
Report Date: 08/07/2023
Date Signed: 08/07/2023 12:01:13 PM


Document Has Been Signed on 08/07/2023 12:01 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:CMA CARE HOME 1FACILITY NUMBER:
019201233
ADMINISTRATOR:ABOLENCIA, IMELDAFACILITY TYPE:
740
ADDRESS:4384 GIBRALTAR DRIVETELEPHONE:
(510) 573-0046
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 0DATE:
08/07/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Imelda and Cecilio Abolencia, LicenseeTIME COMPLETED:
12:10 PM
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On 8/7/2023 at 9:24 AM, Licensing Program Analyst (LPA) L. Fici and arrived announced to conduct a Pre-licensing inspection visit. LPA met with Imelda Abolencia, Licensee, and explained the purpose of the visit. The facility currently has no residents who reside in the facility.

LPA toured facility with licensee, including but not limited to four (4) bedrooms, two (2) bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 68 degrees F and hot water temperature was maintained at 113.4 degrees F in common area bathroom. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were interconnected and functional. Fire extinguisher was last serviced on 3/6/2023

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

No deficiencies cited during inspection



Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023
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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