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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200563
Report Date: 11/30/2022
Date Signed: 12/02/2022 03:05:28 PM

Document Has Been Signed on 12/02/2022 03:05 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:MISSION-HOPE DAY PROGRAM-ANTIOCHFACILITY NUMBER:
079200563
ADMINISTRATOR:GAMEZ, JUANITA NIMFA YFACILITY TYPE:
775
ADDRESS:10 SOUTH LAKE DRIVETELEPHONE:
(925) 706-7517
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 49CENSUS: 37DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria Cunanan, Case Manager, TIME COMPLETED:
12:15 PM
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On 11/30/2022 at 11:30AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Maria Cunanan, Case Manager, and explained the purpose of the visit. Program Director, Mitzi Wardini, arrived at 11:55AM.

Upon entry, LPA's temperature was not checked. Facility has 2 entrances, 1 for visitors and staff, and another for clients. LPA observed screening stations at both entrances that contained hand sanitizer and sign-in log. LPA toured facility including but not limited to common areas, bathrooms, and kitchens. All hand washing stations were equipped with soap, and paper towel, and hand washing poster. Fire extinguishers last serviced 11/23/2022. Hot water temperature measured at 117.0 degrees F.

During record review, LPA observed facility has a copy of Infection Control Plan Plan on file. LPA observed PPE and paper supplies are sufficient.

No deficiencies cited during visit.

Exit interview conduct and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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