<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200400
Report Date: 08/09/2022
Date Signed: 08/09/2022 11:54:23 AM

Document Has Been Signed on 08/09/2022 11:54 AM - 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: DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Shugen Tio, Administrator TIME COMPLETED:
11:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/9/2022 at 9:45 AM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an infection control annual required inspection. LPA met with S2, LPA called Administrator Shugen Tio to inform her the purpose of the visit, Administrator arrived after 30mins. 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 (mask). Facility has a mitigation plan & infection control plan which was reviewed during annual visit. Facility maintains record of routine screening for residents and staff.

Technical assistance provided for FIT testing:
1. LPA strongly recommend updating covid19 training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control.

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: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1