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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200285
Report Date: 08/18/2022
Date Signed: 08/18/2022 11:58:43 AM

Document Has Been Signed on 08/18/2022 11:58 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:VIA CENTERFACILITY NUMBER:
079200285
ADMINISTRATOR:MCGEE, ANGELAFACILITY TYPE:
735
ADDRESS:133 HEATHER DRIVETELEPHONE:
(415) 613-9372
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 5DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Anteneh Nisrane, caregiverTIME COMPLETED:
11:15 AM
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On 08/18/2022 at 10:50am Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct infection control inspection LPA met with Caregiver, Anteneh Nisrane and explained the purpose of the visit. House Manager Deberitu Mekonnen arrived at approximately 11:20am.

During the Infection Control Inspection, LPA toured facility including but not limited to common areas, kitchen, bedrooms, and 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. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Visitors policy is posted on the front door. Facility staff were observed wearing masks. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

The following forms are to be updated and submitted to CCLD by 8/25/2022

-LIC500 Personnel Report

-LIC308 Designation of Administrative Responsibility

-LIC610D Emergency Disaster Plan

-An updated copy of Administrator certificate


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: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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