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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600757
Report Date: 10/06/2021
Date Signed: 10/06/2021 03:59:30 PM

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:FAMILY COURTYARDFACILITY NUMBER:
075600757
ADMINISTRATOR:TEJERO, NORMAFACILITY TYPE:
740
ADDRESS:2840 SALESIAN AVENUETELEPHONE:
(510) 235-8284
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:70CENSUS: 48DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Norma Tejero, AdministratorTIME COMPLETED:
04:05 PM
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On 10/06/2021 at 1:45 PM, Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPA's met with Norma Tejero, Administrator, and explained the purpose of the visit.

Upon entry, LPAs observed a COVID signage on front entrance. LPAs temperature was not checked. There was not a screening station at front entrance. LPAs toured facility including but not limited to common areas, bathrooms, kitchen, and backyard. LPAs observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and hand washing posters.

During record review, LPAs observed visitors log. LPAs were given a copy of the mitigation plan (LIC800) during visit. LPAs observed food and paper supply is sufficient. LPAs did not observe 30-day supply of PPE.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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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