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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601221
Report Date: 11/17/2021
Date Signed: 11/17/2021 06:24:30 PM

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:LARKEY PARK HOME CAREFACILITY NUMBER:
075601221
ADMINISTRATOR:NICULA, MIHAELAFACILITY TYPE:
740
ADDRESS:2532 LARKEY LANETELEPHONE:
(925) 287-8590
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:6CENSUS: 1DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mihaela NiculaTIME COMPLETED:
06:31 PM
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Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrator and Licensee Mihaela Nicula. LPA observed 2 staff wearing face masks during visit. Facility has a completed mitigation plan in place dated 01/18/2021 to mitigate the spread of COVID-19.

LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check is done at entry for all staff, residents, and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette, and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards.

Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. Infection control designated leader is Mihaela Nicula. All staff and residents are fully vaccinated. There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper & PPE supplies were observed stored in the facility. Facility room temperature was maintained at a comfortable level and the water was at 120 degrees Fahrenheit. A certified administrator is on site more than the minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged and last inspected December 2020. Smoke and Carbon monoxide detectors were operational.

No deficiencies cited during this visit. Exit interview conducted and a copy of this report was provided to the administrator.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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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