<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601451
Report Date: 05/23/2022
Date Signed: 05/23/2022 05:36:57 PM


Document Has Been Signed on 05/23/2022 05:36 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:KARO MINA CARE HOMEFACILITY NUMBER:
075601451
ADMINISTRATOR:EWEDA, MONAFACILITY TYPE:
740
ADDRESS:2866 LARAMIE AVENUETELEPHONE:
(925) 551-8263
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 2DATE:
05/23/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Mona Eweda, AdministratorTIME COMPLETED:
05:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/23/2022 at 4:20 PM, Licensing Program Analyst (LPAs) L. Francisco and L. Fici arrived unannounced to conduct a Proof of Correction visit. LPAs were greeted by Caregiver, John Awad. Administrator, Mona Eweda later arrived at 4:50 PM. During proof of correction visit, LPAs toured facility including but not limited to bedrooms, bathrooms, common areas, garage and backyard.

For deficiency 87405(d)(2), LPAs observed S1 and S2 have completed their vaccination. Deficiency cleared.

For deficiency 87355(e)(1), LPA observed S3 is still currently working at the facility.

A total of $800 Civil Penalty is being assessed today for the period of 5/18/2022 to 5/23/2022 for failure to clear deficiency for section 87355(e)(1).

Civil Penalties will continue to be assessed daily until corrected.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1