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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200268
Report Date: 03/19/2024
Date Signed: 03/19/2024 12:45:31 PM

Document Has Been Signed on 03/19/2024 12:45 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: 10DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:MINDY LEE, ADMINISTRATORTIME COMPLETED:
01:10 PM
NARRATIVE
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On 3/19/2024 at 9:50am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced annual 1-year required inspection. LPA met with Mindy Lee Administrator and explained the purpose of the visit.

LPA toured the facility including but not limited to 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. LPA observed 7 staff members and 10 clients present at the facility during visit. All indoor passageways are kept free of obstruction. A comfortable temperature for clients is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. The supply hygiene supplies are available for clients.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 10/19/2023. Fire drill last conducted 2/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ASIAN FAMILY RESOURCE CENTER
FACILITY NUMBER: 079200268
VISIT DATE: 03/19/2024
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continued from LIC 809

LPAs observed the following deficiencies:

- At 10:25am LPA observed unlocked knives in the kitchen cabinet.
-At 10:31am LPA observed unlocked Goo Gone spray located in a box in the office area.
-At 10:34am LPA observed unlocked RAID bug spray in a unlocked cabinet.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/29/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate


The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/19/2024 12:45 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/19/2024 at 12:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ASIAN FAMILY RESOURCE CENTER
FACILITY NUMBER: 079200268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having knives unlocked located in a cabinet in the kitchen area and having goo gone and raid in unlocked in a box and a unlocked cabinet which poses a potential health and safety risk to persons in care.
POC Due Date: 03/20/2024
Plan of Correction
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Administrator removed chemicals and locked them in a locked closet and will make sure chemicals will be locked at all times. DEFICENCY CLEARED DURING VISIT.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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