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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601535
Report Date: 07/27/2023
Date Signed: 07/27/2023 12:50:21 PM

Document Has Been Signed on 07/27/2023 12:50 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: 6DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Tomas Salinas, AdministratorTIME COMPLETED:
01:00 PM
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On 07/27/23 around 09:15 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. Tomas Salinas, Administrator (ADM) arrived about 10 minutes later. ADM currently holds a standard certificate (#6023774740). The facility’s fire clearance was approved for six (6) non-ambulatory residents; one (1) may be bedridden.

Upon entry, LPA observed two residents, one eating breakfast and the other watching television. LPA and ADM 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. The facility has an updated Infection Control Plan (ICP) and routine safety drills are conducted. 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 106.5 degrees Fahrenheit (F) and the facility's temperature was 77 degrees (F). Fire extinguisher was observed full and purchased 07/19/23. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

continued on LIC809C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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: CARTER PLACE
FACILITY NUMBER: 075601535
VISIT DATE: 07/27/2023
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...continued from LIC809.

Fire extinguisher was purchased 07/19/23. Emergency Disaster Plan is updated. Safety drills were last conducted 03/2023 and are rotational between AM and PM schedules monthly.

LPA reviewed three (3) staff records, two (2) were complete, and five (5) completed resident records. ADM to complete his personnel file.

The following forms are to be updated and submitted to CCLD 08/10/23:
-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 ADM.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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