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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601535
Report Date: 06/20/2022
Date Signed: 06/20/2022 04:51:43 PM

Document Has Been Signed on 06/20/2022 04:51 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:CARTER PLACEFACILITY NUMBER:
075601535
ADMINISTRATOR:SALINAS, TOMASFACILITY TYPE:
740
ADDRESS:27 CARTER CT.TELEPHONE:
(510) 223-1696
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 6CENSUS: 4DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Caregiver, Robert MilloyTIME COMPLETED:
05:00 PM
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On 06/20/2022 at 03:35 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. LPA was informed that the Administrator, Tomas Salinas is out of town.

Facility has a COVID-19 mitigation plan on file and routine safety drills are conducted. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, COVID-19 signage, and a sign-in log. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, storage area and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. Caregiver to post 20 seconds to hand washing signs and add covered garbage cans to shared bathrooms. LPA reviewed staff and residents' files; all vaccinated. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and garbage cans. There is a surplus of PPE stored in the downstairs area and centrally located inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 107.2 degrees Fahrenheit (F) and the facility's temperature was 82 degrees (F). Fire extinguisher was observed full along with two newly purchased ones. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided to Caregiver, Robert Milloy.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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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