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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441114
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:04:48 PM

Document Has Been Signed on 08/04/2022 03:04 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:MITCHELL HOMEFACILITY NUMBER:
071441114
ADMINISTRATOR:CECILIA T. DE LEONFACILITY TYPE:
735
ADDRESS:1092 MITCHELL WAYTELEPHONE:
(510) 223-6970
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 6CENSUS: 3DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Pablo De LeonTIME COMPLETED:
03:00 PM
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On 08/04/22 at 01:30 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual Infection Control Inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit to the Administrator, Pablo DeLeon (ADM).

LPA obtained a resident roster and staff roster. LPA observed a screening station at the entry that contained, hand sanitizer, masks, gloves, COVID-19 signage. Advised to keep a thermometer and a visitor sign-in log at the entry. LPA toured the facility including, but not limited to common areas, bathroom, kitchen, garage, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. ADM to post 20 seconds to hand washing sign in the kitchen and create an isolation cart for infection control. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and covered garbage cans. There is a surplus of PPE centrally located inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 105.8 degrees Fahrenheit (F). Fire extinguisher was observed full and last inspected on 06/06/2022. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)
-Infection Control Plan

Exit interview conducted and a copy of this report provided to Pablo De Leon, Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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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