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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601041
Report Date: 04/08/2024
Date Signed: 04/08/2024 12:12:13 PM

Document Has Been Signed on 04/08/2024 12:12 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GINES RESIDENTIAL CARE HOME IIIFACILITY NUMBER:
075601041
ADMINISTRATOR/
DIRECTOR:		GINES, ERLINDAFACILITY TYPE:
740
ADDRESS:2565 STONE VALLEY ROADTELEPHONE:
(925) 743-1146
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY: 6CENSUS: 4DATE:
04/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:39 AM
MET WITH:Licensee, Erlinda GinesTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 04/08/2024 at 11:39 AM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of CCLD receiving notification of a Resident being relocated to facility due to a fire at another facility. LPA met with Administrator, Erlinda Gines and explained the purpose of the visit.

LPAs toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 114.2 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked. Smoke detectors are interconnected with the sprinkler system. A comfortable temperature was maintained at 71 degrees F. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 04/18/2023. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

LPA spoke with R1 to see how they are adjusting to the facility. R1 has dementia and was unable to give coherent answers . R1 is currently on Hospice. R1 was seen by the doctors this morning and sustained no injuries due to fire. Administrator is still awaiting residents file.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.



SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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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