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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200310
Report Date: 10/22/2021
Date Signed: 10/22/2021 11:29:49 AM

Document Has Been Signed on 10/22/2021 11:29 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 PEPPERWOODFACILITY NUMBER:
079200310
ADMINISTRATOR:DEL ROSARIO, MARKFACILITY TYPE:
735
ADDRESS:109 JUNIPER COURTTELEPHONE:
(925) 768-6177
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 6DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mark Del Rosario AdministratorTIME COMPLETED:
11:40 AM
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On 10/22/2021 at 10:30am Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct infection control inspection. LPA's met with Mark Del Rosario administrator, and explained the purpose of the visit

During the Infection Control Inspection, LPAs toured facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms. There is one central entry point for universal screening for staff, residents and visitors. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Visitors policy is posted on the front door. 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: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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