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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200378
Report Date: 10/23/2024
Date Signed: 10/23/2024 12:01:04 PM

Document Has Been Signed on 10/23/2024 12:01 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/
DIRECTOR:		TASHA WOODSFACILITY TYPE:
735
ADDRESS:4680 PINOT COURTTELEPHONE:
(925) 679-1962
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 4DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Tasha Woods, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:23 PM
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On 10/23/2024 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson, arrive to conduct an unannounced 1-Year required inspection, LPA met with Tasha Woods, Administrator and explained the purposed of the visit. The administrator currently holds a certificate (#7009577735) that expires on 10/14/2026. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) total bedrooms and two (2) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 68 degrees 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 119.1 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. 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 purchased on 04/17/2024. Fire Drill last conducted on 10/01/2024. Emergency Disaster Plan was last posted on 10/22/2024. First aid kit was observed to be complete.

Continued LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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: 10/23/2024
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Continued from LIC809

Three (3) staff records were reviewed, and all staff have first aid certification. All four (4) clients' records reviewed, current, and complete.

LPA also reviewed a sample of clients' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/30/2024:


· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Record(updated)
· Liability Insurance
· Surety bond
· Client Roster

No deficiencies cited during visit.

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

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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