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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200586
Report Date: 09/08/2022
Date Signed: 09/08/2022 05:27:08 PM

Document Has Been Signed on 09/08/2022 05:27 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:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:Ashley Fernandez, AdministratorTIME COMPLETED:
05:55 PM
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On 09/08/2022 at 4:50 pm Licensing Program Analysts (LPAs) C. Fowler and L. Alexander arrived unannounced to conduct infection control inspection LPA met with administrator, Ashley Fernandez and explained the purpose of the visit

During the Infection Control Inspection, LPA toured facility including but not limited to common areas, kitchen, bedrooms, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. 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 signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Visitors policy is posted on the front door. 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 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: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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