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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200400
Report Date: 08/30/2021
Date Signed: 08/30/2021 12:03:45 PM

Document Has Been Signed on 08/30/2021 12:03 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:DALI CARE HOME, INC.FACILITY NUMBER:
079200400
ADMINISTRATOR:SHUGEN TIOFACILITY TYPE:
735
ADDRESS:22 DALI COURTTELEPHONE:
(925) 418-4535
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Maricris Molina & Shugen Tio TIME COMPLETED:
12:20 PM
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On 8/30/2021 at 10:10 AM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an infection control annual required inspection. LPA met with Maricris M. & Administrator Shugen Tio. Facility has census of 6. Facility is a level 4i.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. No bodies of water observed at the facility. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days.

Facility has enough 2-day perishable food 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. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

Technical assistance provided for FIT testing:
1. Facility Administrator will conduct FIT testing for all staff, document will need to be submitted to LPA on or before Sept. 17, 2021.
Administrator stated she'll do the following: (technical assistance provided)
1. Purchase trash bins with lids.

No deficiency cited during the visit.
Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
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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