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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601141
Report Date: 04/02/2024
Date Signed: 04/02/2024 04:56:00 PM


Document Has Been Signed on 04/02/2024 04:56 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:ST. CLARE'S HOME FOR SENIORSFACILITY NUMBER:
075601141
ADMINISTRATOR:SALINAS, RAMONFACILITY TYPE:
740
ADDRESS:893 SAN PABLO AVE.TELEPHONE:
(510) 724-5555
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:12CENSUS: 7DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:SARAH MAY VIRAY, CAREGIVERTIME COMPLETED:
05:30 PM
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On 4/2/2024 at 2:40pm, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Administrator/Caregiver Sarah May Viray, and explained the purpose of the visit. Administrator, Marivic Salinas, arrived at 2:55pm.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of eight (8) bedroom, two (2) occupied by staff and five and one half (5.5) bathrooms. LPA did not observe any bodies of water. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 07/22/2023. Emergency disaster plan last updated 2/29/2024. First aid kit was observed to be complete.

Three (3) staff records were reviewed. LPA also reviewed four (4) resident records and they were current and complete.


continue on LIC 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ST. CLARE'S HOME FOR SENIORS
FACILITY NUMBER: 075601141
VISIT DATE: 04/02/2024
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continue from LIC 809

The following forms are to be updated and submitted to CCLD by 04/10/24:
-Resident Roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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