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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601057
Report Date: 02/26/2023
Date Signed: 02/26/2023 03:24:15 PM


Document Has Been Signed on 02/26/2023 03:24 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:AMERICAN LEGACY CARE HOME, INCFACILITY NUMBER:
075601057
ADMINISTRATOR:CARBONEL, LELIA C.FACILITY TYPE:
740
ADDRESS:1778 CHAPARRAL DRTELEPHONE:
(925) 439-5663
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 5DATE:
02/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Lelia Carbonel, AdministratorTIME COMPLETED:
03:30 PM
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On 2/26/2023 at 2:40PM, Licensing Program Analyst (LPA) L. Hall arrived arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Lelia Carbonel and explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 110.8 degrees Fahrenheit. Fire extinguisher last serviced on 1/16/2023. LPAs observed a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the infection control plan on file. LPA observed PPE and paper supplies are sufficient.

No deficiencies cited during visit.

Exit interview and 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: 02/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2023
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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