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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200268
Report Date: 03/29/2022
Date Signed: 04/27/2022 08:34:11 AM

Document Has Been Signed on 04/27/2022 08:34 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:ASIAN FAMILY RESOURCE CENTERFACILITY NUMBER:
079200268
ADMINISTRATOR:MINDY LEEFACILITY TYPE:
775
ADDRESS:12240 SAN PABLO AVETELEPHONE:
(510) 970-9750
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY: 30CENSUS: 7DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Administrator, Mindy LeeTIME COMPLETED:
11:30 AM
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03/29/2022 at 9:07 am, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection for infection control and was met by Program Coordinator, Sun Karnsouvong. LPA informed Administrator, Mindy Lee via telephone about the purpose of the visit. Administrator said she'd arrive in about 20 minutes.


At 9:33 am, LPA observed one non-ambulatory client enter the facility and greeted by staff. At 9:37 am, Administrator arrived, introduced herself, supplied the staff roster. LPA observed the outside area and toured the facility inside and out including, but not limited to the program activity area, bathroom, kitchen, and meeting room. Facility was observed clean and odor free. Passageways and hallways were free of obstruction. The hot water measured at 117.5 degrees Fahrenheit. There was a sufficient supply of gowns, sanitizer, gloves, face shields, surgical masks, soap, paper supplies and N95's. First aid kit was observed, fire extinguisher last serviced 11/27/2021, smoke detectors were observed, the room temperature was noted at 66 degree Fahrenheit. The Day Program does not handle P & I money, medications or serve food to the clients.

No citations made during this visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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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