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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441208
Report Date: 04/05/2022
Date Signed: 04/28/2022 04:07:29 PM

Document Has Been Signed on 04/28/2022 04:07 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:DYER FAMILY CARE HOMEFACILITY NUMBER:
071441208
ADMINISTRATOR:DYER, WANDAFACILITY TYPE:
735
ADDRESS:391 BECK STREETTELEPHONE:
(510) 232-7829
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 4CENSUS: 1DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Wanda DyerTIME COMPLETED:
04:15 PM
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On 04/05/2022 at 9:35 AM Licensing Program Analyst (LPA) L. Holmes attempted to conduct an unannounced annual - infection control visit. LPA arrived at the facility, rang the door bell, and it was answered by a gentleman. LPA asked was the Administrator, Wanda available and he said no; she had left with two of the clients. LPA asked was anyone else available and he replied no; he's her brother and just does a little work around the facility. At 9:45 AM, LPA left the premises, called the Administrator, received the voicemail and left a message requesting a callback. LPA observed the gentleman cutting the lawn after LPA left the facility.

On 04/28/2022 at 03:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived for a second attempt, unannounced, to conduct an Infection Control Inspection, LPA was greeted by the Administrator, Wanda Dyer (ADM) and explained the purpose of the visit.
A screening station is at the entry with thermometer and hand sanitizer. ADM to add COVID-19 signage throughout the facility, maintain a sign-in log for visitors. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen and outside. Advised ADM to add 20 second handwashing signs and covered trash cans to shared bathrooms. Bathrooms were equipped with grab bars, soap and paper towels. Hot water temperature in the shared clients' bathroom was measured at 116.7 degrees Fahrenheit (F) and facility temperature was 72 degrees (F). Fire extinguisher observed full. Smoke and Carbon Monoxide detectors observed operational. LPA advised ADM to create an isolation cart in the event of a COVID-19 outbreak.
The following forms are to be updated and submitted to CCLD on or before 05/12/2022.
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)
Exit interview conducted and a copy of this report provided.


SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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