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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200379
Report Date: 07/27/2022
Date Signed: 07/27/2022 04:10:07 PM


Document Has Been Signed on 07/27/2022 04:10 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:ABIGAIL'S GUEST HOMEFACILITY NUMBER:
079200379
ADMINISTRATOR:ABIGAIL SANTOSFACILITY TYPE:
740
ADDRESS:10061 LA PAZ AVENUETELEPHONE:
(925) 828-9660
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 6DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Marilou Aguilar, CaregiverTIME COMPLETED:
04:25 PM
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On 7/27/2022 at 3:30 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPA was greeted by Care Staff, Marilou Aguilar and LPA explained the purpose of the visit. Administrator was not available during visit.

During the Infection Control Inspection, LPA toured facility with Care Staff including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff.

At 3:57 PM, LPA reviewed 3 staff records and 3 of 3 have health screening and TB test on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff.


REPORT CONTINUES ON 809C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ABIGAIL'S GUEST HOME
FACILITY NUMBER: 079200379
VISIT DATE: 07/27/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 8/1/2022
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance
  • Current Administrator’s Certificate


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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