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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201345
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:35:11 PM

Document Has Been Signed on 05/23/2024 01:35 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:RIVER OAK RESIDENTIAL CARE HOMEFACILITY NUMBER:
019201345
ADMINISTRATOR/
DIRECTOR:		RIVERA-VALLESTERO, JAMIEFACILITY TYPE:
735
ADDRESS:2088 TRAFALGAR AVETELEPHONE:
(510) 676-4569
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 0DATE:
05/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Jamie Rivera-Vallestero/Applicant-Administrator and
Corporate Officer/Applicant Janice Lapuz		TIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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At 10:50 a.m. on this day, May 23, 2024, Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing inspection, and met with Jamie Rivera-Vallestero, applicant-administrator and
Corporate Officer/Applicant Janice Lapuz. License application is for six (6) total capacity, of which 2 may be non-ambulatory. Fire clearance was granted on April 10, 2024; however, LPA observed the following: facility sketch is a screen shot and does not clearly indicate the exit doors and windows and utility shut off locations. Both sketch and STD850 didn't indicate which bedroom(s) is for non-ambulatory. LPA requested to submit a completed sketch which LPA received on May 20, 2024.

Applicant submitted the LIC9282 Infection Control Plan and LIC610D Emergency Disaster Plan to Central Application Bureau (CAB) analyst.

LPA toured the facility inside out with applicant-administrator. LPA inspected the living and family rooms, kitchen, bedrooms, bathrooms, garage, front, side and backyard. Bedrooms were observed appropriately furnished with adequate lighting and drawers. The facility has sufficient towels and linens. Supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed adequate for residents' use. There’s 7 days supplies of non-perishables and 2 days of perishables. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. Kitchen cabinets where knives and dishwashing liquid were stored were observed with locks. Central storage for medications and cabinets for residents and staff files were also observed with locks. Bathrooms were observed with grab bars. All trash cans were observed with foot pedal operated lids. Passage way, hallways and ramp were free of hazards and obstructions


....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: RIVER OAK RESIDENTIAL CARE HOME
FACILITY NUMBER: 019201345
VISIT DATE: 05/23/2024
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Hot water temperature in one of the bathrooms was tested and measured at 109 degrees Fahrenheit. First aid was complete with manual. Smoke and carbon monoxide detectors were tested and observed in operating condition. Fire extinguisher checked, observed fully charge, and receipt showed purchased. 12/08/2023.

LPA observed the following:
-at 11:31 a.m., one of the fence gates locked. Applicant removed the lock during inspection.
-the facility sketches need more corrections to reflect the following:
  • linen closets
  • doors on the all the closets in the residents' rooms.
  • only one window in the family room.
  • storage in the backyard.


On this same day, applicant-administrator corrected the sketches and provided copies to LPA. LPA inforned that the sketches will be forwarded to Central Application Bureau (CAB) analyst who in turn will submit to Fire Department along with a new STD850 Fire Safety Inspection Request.

On this same day, LPA tested the facility telephone and observed working. LPA obtained a signed letter from the applicant stating a request to update the facility telephone number.

Upon receipt of new approved STD850 and final review of application, license to be granted by CAB analyst.

Exit interview conducted, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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