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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201390
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:30:59 PM

Document Has Been Signed on 11/07/2024 01:30 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:BGC DAHILL RESIDENTIAL CAREFACILITY NUMBER:
019201390
ADMINISTRATOR/
DIRECTOR:		ANDALIS, MARIA VICTORIAFACILITY TYPE:
735
ADDRESS:1824 DAHILL LANETELEPHONE:
(510) 325-2414
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 0DATE:
11/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Eugene Elendu/Applicant, Maria Victoria 'Vickee' Andalis/Administrator and Maria Golitzen/ConsultantTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At 11:30 a.m. on this day, November 7, 2024, Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing inspection, and met with Eugene Elendu, applicant, Maria Victoria 'Vickee' Andalis, administrator, and Maria Golitzen, consultant. License application is for six (6) total capacity, ambulatory only. This is an initial application for license for this location. Fire clearance was granted on May 15, 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 and consultant. LPA inspected the courtyard, living room, dining area, 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. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for central storage for medications was observed with lock. All trash cans were observed with foot pedal operated lids. Passage way and hallways were free of hazards and obstructions. Storage for cleaning supplies in the garage was observed with lock. Facility has activity materials, patio table, chairs and umbrella for residents' use.

Water temperature in the common bathroom was tested and measured at 116. 2 degrees Fahrenheit. Facility is equipped with 2 in 1 carbon monoxide and smoke detectors that were tested and observed functional. First aid kit was inspected. Fire extinguisher was checked, observed fully charge with tag showed serviced May 8, 2024.

......continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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: BGC DAHILL RESIDENTIAL CARE
FACILITY NUMBER: 019201390
VISIT DATE: 11/07/2024
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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. LPA also received copies documents for transfer of criminal background clearance for Maria Golitzen.

LPA observed the following:
-at 11:40 a.m., locks of the drawers and cabinet in the kitchen where sharps and kitchen cleaning agents are kept were magnetic locks.
-at 11:52 a.m., pieces of wood, mirrors, pipes, cinder block and brick in the side yard and backyard.
-at 12:15 p.m., first aid kit has no thermometer.

Applicant and/or administrator to submit the following proof of corrections by November 21, 2024:
-replace the magnetic lock with lock operable with key and submit pictures.
-clean the yard and submit pictures.
-purchase thermometer and submit proof of purchase and picture.

Upon receipt of the proof of corrections, LPA will inform CAB. Issuance of license is pending upon final review 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: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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