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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201296
Report Date: 12/27/2023
Date Signed: 12/27/2023 03:44:24 PM

Document Has Been Signed on 12/27/2023 03:44 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:TINS ADULT DAY PROGRAMFACILITY NUMBER:
019201296
ADMINISTRATOR:ILAO, CRISTINAFACILITY TYPE:
775
ADDRESS:33131 ALVARADO NILES RDTELEPHONE:
(650) 580-5111
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 30CENSUS: 0DATE:
12/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cristina IlaoTIME COMPLETED:
04:05 PM
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On this day at around 2pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived to conduct an announced pre licensing inspection and met with applicant Cristina Ilao. The facility has an approved fire clearance for 30, 15 of which are ambulatory and 15 are non ambulatory.

Upon entry, LPA observed four different rooms on the right side enclosed in glass designated as Meeting Room, Administrator office, Music Room and Arts and Craft Room. On the left side is the Reception area. There is a kitchen/dining area as well as Nurse Station/Changing Room. The Nurse/Changing Room has a bed, chair, hoyer lift, table, first aid kit and telephone. There are two bathrooms, one for men and one for women. Kitchen was inspected and observed with a dining table and 5 chairs, cabinets with locks, refrigerator and microwave. Day Program has sufficient supply of paper, hygiene products, PPEs, etc. There are two locked cabinets for cleaning chemicals. One is located in the kitchen and the other is in the hallway next to the Changing Room. LPA observed shelves for clients. There are activity materials observed during the visit.

Hot water temperature was tested in one of the restrooms and measured at 119 degrees Fahrenheit. There are two First aid kits observed to be current and complete. One is located in the dining area and the other is located in the Nurse/Changing Room. There are three fire extinguishers with service tags dated 10/30/2023 observed. The day program will hire a Licensed Vocational Nurse (LVN) on site.

The day program is ready to be licensed.

This report will be submitted to Central Applications Branch (CAB) and a final review of the application will be conducted. Additional requirements may still be required.

Exit interview was conducted and a copy of this report was provided to applicant.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023
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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