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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200176
Report Date: 12/20/2022
Date Signed: 12/20/2022 04:52:37 PM

Document Has Been Signed on 12/20/2022 04:52 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:S.M. CARE HOME 1FACILITY NUMBER:
079200176
ADMINISTRATOR:HENRY LIMFACILITY TYPE:
735
ADDRESS:18 VIGNOLA COURTTELEPHONE:
(925) 625-3888
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
12/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Henry Lim, Administrator TIME COMPLETED:
05:10 PM
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On 12/20/2022 at 3:30 PM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an infection control annual inspection. LPA met with Administrator Henry Lim. Facility has census of 6.

LPA toured the facility with Henry Lim, including but not limited to the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Visitors policy is posted on the front entrance. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. Smoke detectors and carbon monoxide were in operating condition during visit.

Facility has enough supplies of PPEs, paper supplies and hygiene supplies. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE (mask). Facility has a mitigation plan an infection control plan was received and reviewed during the visit. Facility maintains record of routine screening for residents and staff.

No deficiency cited during the visit.

Exit interview conducted. Copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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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