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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601205
Report Date: 02/08/2023
Date Signed: 02/08/2023 11:31:09 AM


Document Has Been Signed on 02/08/2023 11:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MORAGA RETREAT CAREFACILITY NUMBER:
075601205
ADMINISTRATOR:BLAJ, ANAMARIAFACILITY TYPE:
740
ADDRESS:715 MORAGA ROADTELEPHONE:
(925) 376-2273
CITY:MORAGASTATE: CAZIP CODE:
94556
CAPACITY:6CENSUS: 5DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Lizette Ng, staffTIME COMPLETED:
11:45 AM
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On 2/8/2023 starting at 10:50 a.m., Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct Infection Control Inspection. LPA met with staff and disclosed the purpose of the visit. Administrator was absent during the inspection.

Upon entry, LPA’s temperature was checked and asked to sign-in with answering Covid-19 symptoms by the staff. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, common areas, and outdoor areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE.

Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors.

No deficiency cited during visit. Exit interview conducted with staff, and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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