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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200127
Report Date: 02/15/2022
Date Signed: 02/15/2022 12:48:10 PM

Document Has Been Signed on 02/15/2022 12:48 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:LAMORINDA ADULT RESPITE CENTERFACILITY NUMBER:
079200127
ADMINISTRATOR:ELIZABETH J. MONTGOMERYFACILITY TYPE:
775
ADDRESS:433 MORAGA WAYTELEPHONE:
(925) 254-3465
CITY:ORINDASTATE: CAZIP CODE:
94563
CAPACITY: 35CENSUS: 11DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Kathleen Januszewski, AdministratorTIME COMPLETED:
01:00 PM
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On 2/15/2022 starting at 11:24 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator Kathleen Januszewski and disclosed the purpose of the visit.

Upon entry, LPA toured facility including but not limited to front entrance, hand washing stations, bathrooms, activity rooms, kitchen, common areas, and outdoor areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were not observed at screening station. Cough/sneeze etiquette and hand washing posters were not observed. Therefore, Technical Assistances (TAs) were provided to Administrator.

Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan and Emergency Disaster Plan on file.

No deficiency cited during visit. Exit interview conducted with Administrator, and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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