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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200614
Report Date: 12/05/2022
Date Signed: 12/05/2022 03:42:48 PM


Document Has Been Signed on 12/05/2022 03:42 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:ARLINGTON CARE HOMEFACILITY NUMBER:
079200614
ADMINISTRATOR:CINDY HONGYAN CHENFACILITY TYPE:
740
ADDRESS:2545 ARLINGTON BLVDTELEPHONE:
(510) 316-6687
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:6CENSUS: 5DATE:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Cindy Hongyan Chen, AdministratorTIME COMPLETED:
04:00 PM
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 12/05/2022 at 02:40 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. Cindy Hongyan Chen, Administrator (ADM) was telephoned by the staff member and arrived about 10 minutes later.

Facility has a COVID-19 mitigation plan on file. LPA requested a staff and resident roster. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, masks, gloves, COVID-19 signage, and a visitor sign-in log. ADM to remove, "No Visitors" sign at entrance. LPA toured the facility inside and out including, but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. PPE is centrally stored in the garage. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. ADM to post 20 seconds to hand washing signs. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods; groceries are purchased once a week. All hand washing stations were equipped with soap, paper towels and covered garbage cans; ADM removed hand towels. Hot water temperature in the shared residents' bathroom was measured at 112 degree Fahrenheit (F) and the facility's temperature was 70 degree (F). Fire extinguisher was observed full and last inspected on 12/15/2021. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Faxed)
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Faxed)
-An updated copy of Administrator Certificate(s) (Reviewed)

Exit interview conducted and a copy of this report provided to ADM.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022
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