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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601304
Report Date: 12/09/2021
Date Signed: 12/21/2021 02:32:37 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:TARA HILLS CARE HOMEFACILITY NUMBER:
075601304
ADMINISTRATOR:ENRIQUEZ, MIAFACILITY TYPE:
740
ADDRESS:908 TARA HILLS DRIVETELEPHONE:
(510) 910-6165
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:6CENSUS: 6DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Evelyn Pinon, CaregiverTIME COMPLETED:
10:55 AM
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On 12/09/2021 at 8:45am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct Infection Control Inspection. LPA met with Evelyn Pinon Caregiver, Administrator, Mia Enriquez arrived at 9:11am LPA explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. 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, social distancing and hand washing posters were observed. Facility maintains record of routine screening for residents and staff

Facility staff was observed not wearing face mask. Facility dose not have a 30-day supply of PPEs. Facility Provided LPA with a copy of their mitigation plan during visit. Facility has a staff member that is not associated but is associated at Wonder Years Care home, Administrator provided LPA with form LIC 9182.

No deficiencies cited during visit. Exit interview conducted and 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: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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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