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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200260
Report Date: 02/21/2023
Date Signed: 02/21/2023 10:51:12 AM

Document Has Been Signed on 02/21/2023 10:51 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BUENAVISTA HOME AT PINOLE VALLEYFACILITY NUMBER:
079200260
ADMINISTRATOR:PEREZ, RONALDOFACILITY TYPE:
735
ADDRESS:3799 PINOLE VALLEY ROADTELEPHONE:
(510) 223-0880
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 6CENSUS: 6DATE:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:JEMAR DELA TORRE, CAREGIVERTIME COMPLETED:
11:00 AM
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On 02/21/2023 at 9:55am Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct infection control inspection LPA met with Caregiver, Jemar Dela Torre and explained the purpose of the visit, Supervisor Jober Galera arrived at approximately 10:15am.

During the Infection Control Inspection, LPA toured facility including but not limited to common areas, kitchen, shared bathrooms. to front entrance, screening station, hand washing stations, common areas. 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. Hand washing posters, soap, and paper towel, hand blow dryer was observed at hand washing stations. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Visitors policy, mask, social distance, cough equate signs posted in binder due to clients removing signs when posted. Facility staff were observed wearing masks. Facility has a 30-day supply of PPE maintained at a central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2023
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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