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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200320
Report Date: 09/02/2021
Date Signed: 09/03/2021 01:57:52 PM

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:BETHEL CARE HOME ON COTTAGEFACILITY NUMBER:
079200320
ADMINISTRATOR:CARLA BLAJFACILITY TYPE:
740
ADDRESS:36 COTTAGE LANETELEPHONE:
(925) 280-6000
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Carla BlajTIME COMPLETED:
05:00 PM
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On 09/02/2021 at 1:15PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct an Infection Control Inspection. LPA met with staff, Badrudeen Martin and explained the purpose of the visit. Administrator, Carla Blaj was informed of the visit and came as soon as she was able, which was within 60 minutes.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, and outdoor areas. LPA observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed visitors log. LPA observed facility has a copy of Mitigation Plan. LPA observed that PPEs, food, and paper supplies were sufficient.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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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