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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200378
Report Date: 03/05/2024
Date Signed: 03/05/2024 04:55:48 PM

Document Has Been Signed on 03/05/2024 04:55 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:VIERA RESIDENTIAL CARE HOME IIFACILITY NUMBER:
079200378
ADMINISTRATOR:TASHA WOODSFACILITY TYPE:
735
ADDRESS:4680 PINOT COURTTELEPHONE:
(925) 679-1962
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 4DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Tasha Woods AdministratorTIME COMPLETED:
05:05 PM
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On 03/05/2024 at 2:45 PM, Licensing Program Analysts (LPAs) Tonica Syess-Gibson and L. Hall unannounced annual required inspection. LPAs met with Tasha Woods and explained the purpose of the visit. LPAs toured the facility with Administrator Tasha Woods. The facility’s fire clearance was approved for Six (6) Ambulatory clients.


LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms and two (2) bathrooms. 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 degrees Fahrenheit. LPAs 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 105.2 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/01/2023. Emergency Disaster Plan was last posted on 02/01/2022. First aid kit was observed to be complete. Fire drill was last conducted on 02/22/2024.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: VIERA RESIDENTIAL CARE HOME II
FACILITY NUMBER: 079200378
VISIT DATE: 03/05/2024
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Continued from LIC809.


Four (4) staff records reviewed and complete. All Four (4) clients records reviewed, current, and complete. LPAs also reviewed P & I.

The following forms to be updated and submitted to CCLD by 03/12/2024:

· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC308 Designation of facility responsibility
· LIC610D Emergency Disaster Plan


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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