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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601437
Report Date: 07/18/2022
Date Signed: 07/18/2022 01:27:26 PM


Document Has Been Signed on 07/18/2022 01:27 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:AN OAK GROVE MANORFACILITY NUMBER:
075601437
ADMINISTRATOR:VELARDE-BAENS, SHIRLEY A.FACILITY TYPE:
740
ADDRESS:2801 OAK GROVE ROADTELEPHONE:
(925) 926-0405
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 4DATE:
07/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH: SHIRLEY BAENSTIME COMPLETED:
02:00 PM
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On 07/18/22 at 11:00AM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with Administrator Shirley Baens upon entry and toured facility with LPA inside and out.

Facility has a COVID-19 mitigation plan in place dated 01/06/21 that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. All staff and clients have been fully vaccinated and the infection control plan from PIN 22-13-ASC has been completed.

A written Emergency/Disaster plan was posted on the bulletin board for staff, clients and visitors to read. Centrally stored medications were in locked cabinets. The temperature inside of the facility was 78.3 degrees, which was in the safe range. The hot water was 110 degrees, which is in the safe range of 105 to 120 degrees Fahrenheit. Toxic chemicals were stored in locked closets and cabinets, as were sharp objects.

Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged.

Continued on next page LIC 809-C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AN OAK GROVE MANOR
FACILITY NUMBER: 075601437
VISIT DATE: 07/18/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/25/22:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

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

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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