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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200586
Report Date: 10/13/2021
Date Signed: 10/13/2021 04:35:21 PM

Document Has Been Signed on 10/13/2021 04:35 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:FITZPATRICK HILLS MANOR LLCFACILITY NUMBER:
079200586
ADMINISTRATOR:FERNANDEZ,MARIETTAFACILITY TYPE:
735
ADDRESS:2468 FITZPATRICK STREETTELEPHONE:
(510) 862-7199
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 4DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Ashley Ferandez, AdministratorTIME COMPLETED:
04:45 PM
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On 10/13/2021 at 3:45pm Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct infection control inspection LPA's met with administrator, Ashley Ferandez and explained the purpose of the visit

During the Infection Control Inspection, LPAs toured facility including but not limited to common areas, kitchen, bedrooms, and shared bathroom, and common areas. There is one central entry point for universal screening for staff, residents and visitors. Visitors policy is posted on the front door, a sign-in policy, thermometer and sanitizer. Facility staff were observed wearing masks. Facility has a 30-day supply of PPE maintained at a central location and easily accessible for staff. Facility has a hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters and soap, were observed at hand washing stations. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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