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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200176
Report Date: 12/24/2024
Date Signed: 12/24/2024 11:42:47 AM

Document Has Been Signed on 12/24/2024 11:42 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:S.M. CARE HOME 1FACILITY NUMBER:
079200176
ADMINISTRATOR/
DIRECTOR:		HENRY LIMFACILITY TYPE:
735
ADDRESS:18 VIGNOLA COURTTELEPHONE:
(925) 625-3888
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
12/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Henry Lim, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 12/24/2024 at 9:30 AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Henry Lim and explained the purpose of the visit. the facility’s fire clearance was approved for 6 Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 69 degree Fahrenheit.

LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105.9 degree Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. There is a minimum of 7-day supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire Drill last conducted on 10/20/2024. Fire extinguisher was last purchased on 10/03/2024. Emergency Disaster Plan last updated on 07/09/2024. First Aid Kit observed to be complete.



Continue LIC809 C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/24/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: S.M. CARE HOME 1
FACILITY NUMBER: 079200176
VISIT DATE: 12/24/2024
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Continued from LIC809

LPA reviewed all six (6) client records and they were all complete. LPA reviewed six (6) staff records and 6 of 6 have current first aid training and associated to the facility. LPA also reviewed a sample of clients medications and all P&I during visit.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/31/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 D Emergency Disaster Plan


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC809 (FAS) - (06/04)
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