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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601193
Report Date: 02/09/2023
Date Signed: 02/09/2023 04:38:51 PM


Document Has Been Signed on 02/09/2023 04:38 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:DUCRE'S RESIDENTIAL CAREFACILITY NUMBER:
075601193
ADMINISTRATOR:DUCRE, DORIS RUTHFACILITY TYPE:
740
ADDRESS:4400 BELL AVENUETELEPHONE:
(510) 236-8776
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:6CENSUS: 5DATE:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator, Doris DucreTIME COMPLETED:
04:50 PM
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On 02/09/23 at 03:10 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPA was greeted by one client at the door. The Administrator, Doris Ducre (ADM) met LPA at the entry and explained the purpose of the visit.

Facility has a COVID-19 mitigation plan and ICP plan on file. LPA reviewed a staff and resident roster. LPA observed a visitor sign-in log at the entry. Facility has a thermometer, hand sanitizer, masks, face shields, gowns, shoe covers, goggles, gloves, and COVID-19 signage throughout. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, storage, garage and backyard. LPA observed masks, cough etiquette, social distancing and hand washing signs posted throughout. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and covered garbage cans. There is a surplus of PPE stored inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 114.6 degrees Fahrenheit (F) and the facility's temperature was 65 degrees (F). Fire extinguisher was observed full. Smoke/Carbon Monoxide detectors were observed operational and first aid flipper card and supplies for kit were available.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s) (Reviewed)

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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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