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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200320
Report Date: 09/02/2022
Date Signed: 09/02/2022 12:53:26 PM


Document Has Been Signed on 09/02/2022 12:53 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: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:
09/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Carla BlajTIME COMPLETED:
01:15 PM
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On 9/02/22 at 10:15 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon entry, LPA explained the purpose of the visit with staff members and spoke with Administrator (ADM) Carla Blaj over the phone, who arrived a short time thereafter . Staff toured the facility inside and outside with LPA.

Facility has an infection control plan in place that they are following. The designated infection control leader is the ADM. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing.

A written Emergency/Disaster plan was displayed. Centrally stored medications were in locked cabinets. The temperature inside of the facility was 74.8 and the hot water was 118 degrees Fahrenheit, both of which were in the safe range. Toxic chemicals and sharp objects were stored in locked closets and cabinets. Carbon monoxide and smoke detectors were fully functional and the fire extinguisher had been serviced within one (1) year and it was fully charged. An administrator is on site more than the required 20 hour minimum each week to oversee business operations.

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided via email..
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
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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