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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601514
Report Date: 07/16/2021
Date Signed: 07/16/2021 12:37:34 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:PENNY'S GUEST HOMEFACILITY NUMBER:
075601514
ADMINISTRATOR:GARDNER, JOSEFINAFACILITY TYPE:
740
ADDRESS:78 RYEGATE PLACETELEPHONE:
(925) 361-8781
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 5DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Josefina Gardner, AdministratorTIME COMPLETED:
12:45 PM
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On 7/16//2021 at 11:05AM, Licensing Program Analysts (LPAs) C. Fowler and L. Francisco arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Josefina Gardner and explained the purpose of the visit.

Upon entry, we were greeted by staff, LPAs observed hand sanitizer, and COVID-19 signage, LPAs toured facility including but not limited to common areas, bathrooms, kitchen, garage, and backyard. All sinks were equipped with soap, paper towel garbage cans with lids.

During record review, LPAs observed visitors log and temperature log for both residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPE, food and paper supplies are sufficient.

No deficiencies were cited during this inspection.

Exit interview conducted. 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: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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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