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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200360
Report Date: 05/17/2023
Date Signed: 05/17/2023 03:17:48 PM

Document Has Been Signed on 05/17/2023 03:17 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TELECARE HOPE HOUSEFACILITY NUMBER:
079200360
ADMINISTRATOR:GARCIA, DENISE GFACILITY TYPE:
772
ADDRESS:300 ILENE STREETTELEPHONE:
(925) 313-7980
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 16CENSUS: 13DATE:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Denise Garcia, Interim Program AdministratorTIME COMPLETED:
03:30 PM
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On 05/17/2023 at 10:40AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Interim Program Administrator, Denise Garcia and explained the purpose of the visit. The facility’s fire clearance was approved for 16 Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 9 total bedrooms which 9 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 73 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 120.6, 115.4, 95.5 (Bathroom# 2 upstairs) and 111.8 (Staff restroom) degrees Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygienes were available for clients. There is a minimum of one week supply of non-perishable and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/03/22. Emergency Disaster Drill was last posted on 11/2022. First aid kit was observed to be complete. Fire drill was last conducted on 03/2023.

At 11:35am, 7 of 13 clients records were reviewed. At 12:30pm, 4 staff records were reviewed and 3 of 4 have current first aid training and associated to the facility.

Continued LIC809-C....
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TELECARE HOPE HOUSE
FACILITY NUMBER: 079200360
VISIT DATE: 05/17/2023
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 05/24/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
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