079200400-12-14-2023-15-AS-PWAN-CYHQR5-20231214112323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200400
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:23:27 AM

Document Has Been Signed on 12/14/2023 11:23 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	DALI CARE HOME, INC.		FACILITY NUMBER:	079200400
ADMINISTRATOR:	SHUGEN TIO		FACILITY TYPE:	735
ADDRESS:	22 DALI COURT		TELEPHONE:	(925) 418-4535
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	6	CENSUS: 6	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Henry Lim, Administrator Maricris Molina, House Manager		TIME COMPLETED:	11:30 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 12/14/2023 at 9:15 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Henry Lim and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Ambulatory. LPA toured the facility with Maricris including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms and 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 69 degree 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 117.8 degree Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply. Smoke detectors and carbon monoxide were in operating condition during visit. First aid kit was observed to be complete. Fire extinguisher was last purchased on 08/31/2023. Emergency Disaster Drill (Earthquake) was last conducted on 07/04/2023. Fire drill was last conducted on 10/31/2023. Report continues on 809 C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DALI CARE HOME, INC.	FACILITY NUMBER: 079200400
	VISIT DATE: 12/14/2023

NARRATIVE

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At 9:30 AM, LPA reviewed 6 of 6 client records. At 10:15 AM, LPA reviewed 6 staff records and 6 of 6 have current first aid training and associated to the facility. At 10:44 AM, LPA reviewed client medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL via fax by 12/28/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 D Emergency Disaster Plan

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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