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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601490
Report Date: 10/23/2024
Date Signed: 10/23/2024 01:30:00 PM

Document Has Been Signed on 10/23/2024 01:30 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MAUREEN HOUSEFACILITY NUMBER:
075601490
ADMINISTRATOR/
DIRECTOR:		JOSE MICHAEL TORIOFACILITY TYPE:
740
ADDRESS:590 MAUREEN LANETELEPHONE:
(925) 818-6536
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 5DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Alberto Bernardino, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 10/23/2024 at 10:05 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Lea Robes and explained the purpose of the visit. Lea phoned the Licensee/Administrator, Alberto Bernardino to inform. The facility’s fire clearance was approved for capacity of six (6) residents in which all may be non-ambulatory. One (1) resident may be bedridden. Hospice waiver approved for six (6) residents. Administrator certificate #7035909740 expires 10/26/2025. Licensee/Administrator, Alberto, arrived approximately an hour later.

LPA toured facility with Lea including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) total bedrooms which six (6) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

LIC809-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MAUREEN HOUSE
FACILITY NUMBER: 075601490
VISIT DATE: 10/23/2024
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LIC809-C Continued...

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last purchased on 03/21/2024. Emergency Disaster Plan was last posted on 10/23/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/03/2024.

LPA reviewed five (5) residents records. LPA reviewed seven (7) staff records and 7 of 7 have current first aid training and associated to the facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/30/2024:

LIC 308 Designation of Administrative Responsibility - Reviewed
LIC 500 Personnel Report - Reviewed
LIC 610E Emergency Disaster Plan - Reviewed (last page)
Liability Insurance - Reviewed
Current Administrator’s Certificate - Reviewed

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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