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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200617
Report Date: 09/27/2022
Date Signed: 09/27/2022 03:28:53 PM

Document Has Been Signed on 09/27/2022 03:28 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:TERESITA'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
079200617
ADMINISTRATOR:RAMON DE LOS SANTOSFACILITY TYPE:
737
ADDRESS:1058 NIGHTHAWK WAYTELEPHONE:
(925) 420-5603
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 4CENSUS: 4DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Ramon Delos Santos, Administrator TIME COMPLETED:
03:45 PM
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On 9/27/2022 at 12:50PM, Licensing Program Analyst (LPA) L. Ibo conducted an infection control annual inspection and met with S1 and informed him the purpose of the visit. LPA observed 4 clients during the visit, S1 stated that 1 client is at the day program.

LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. Facility has a completed mitigation plan. LPA requested from Administrator to submit a copy of infection control plan and a copy of monkey pox infection control plan.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 72 degrees Fahrenheit. A certified Administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.

No deficiency cited during the visit.

LPA observed covid19 training for all staff that was dated March 2021, LPA requested from Administrator to conduct a new in-service training. Technical assistance provided.

Exit interview conducted copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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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