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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601374
Report Date: 05/05/2022
Date Signed: 05/05/2022 04:32:01 PM


Document Has Been Signed on 05/05/2022 04:32 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:RED MAPLE RESIDENTIAL HOMEFACILITY NUMBER:
075601374
ADMINISTRATOR:HELEN GRACE HERBERTFACILITY TYPE:
740
ADDRESS:7100 MANILA AVENUETELEPHONE:
(510) 778-9084
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:6CENSUS: 5DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:27 PM
MET WITH:Care Staff, Araceli EmerickTIME COMPLETED:
04:45 PM
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On 05/05/2022 at 03:27 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection, LPA was greeted by one staff upon entry and explained the purpose of the visit. The Designated Administrator, Araceli Emerick was telephoned by the staff member and arrived about 15 minutes later.

Facility has a COVID-19 mitigation plan on file. LPA obtained a staff and resident roster. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, masks, face shields, gowns, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. Care staff to post 20 seconds to hand washing signs. There was a sufficient supply of 7-day perishables and 2-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and covered garbage cans. Hot water temperature in the shared residents' bathroom was measured at 109.5 degrees Fahrenheit (F) and facility temperature was 73 degrees (F). Fire extinguisher was observed full and last inspected on 08/04/2021. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD by 05/12/2022:
-LIC500 Personnel Report (Received)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-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: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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