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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200268
Report Date: 12/05/2022
Date Signed: 12/05/2022 12:26:05 PM

Document Has Been Signed on 12/05/2022 12:26 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: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:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mindy Lee, Administrator TIME COMPLETED:
12:30 PM
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12/05/2022 at 11:00 am, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection for Infection Control and was met by Mindy Lee, Administrator (ADM).


Facility has a COVID-19 mitigation and infection control plan on file. LPA obtained a staff and resident roster. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, COVID-19 signage, and a visitor sign-in log. At 11:20 AM, LPA observed 7 staff members present at the facility, zero (0) clients during visit, and was advised one (1) in-person visit is planned for the day. LPA observed the outside area and toured the facility inside including, but not limited to the program activity area, bathrooms, kitchen, and office area. There is an isolation cart and room available for quarantining. The facility was observed clean and odor free. Passageways were free of obstruction. The hot water measured at 106.1 degree Fahrenheit. There was a sufficient supply of gowns, sanitizer, gloves, face shields, surgical masks, N95's, soap and paper supplies and covered garbage cans in all shares areas. The First Aid kit was observed complete, two (2) fire extinguishers were last serviced 10/12/2022, smoke and carbon monoxide detectors were observed operational. The Day Program does not handle P & I money, medications or serve food to the clients.

The following forms are to be updated and submitted to CCLD on or before 12/31/2022:
-LIC500 Personnel Report (Received)
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan

No citations noted during this visit. Exit interview conducted and a copy of this report provided to ADM.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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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