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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200631
Report Date: 09/25/2024
Date Signed: 09/25/2024 04:53:14 PM


Document Has Been Signed on 09/25/2024 04:53 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WELCOME HOME SENIOR RESIDENCE-ALAMO 3FACILITY NUMBER:
079200631
ADMINISTRATOR:JOAN D. RIVERAFACILITY TYPE:
740
ADDRESS:110 PASEO DE SOLTELEPHONE:
(925) 406-4921
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: 6DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Racquel Chou, Licensee TIME COMPLETED:
05:05 PM
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On 09/25/2024 at 1:55PM, Licensing Program Analysts (LPAs) P. Manalo and A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee Racquel Chou and explained the purpose of the visit. The facility’s fire clearance was approved for all non-ambulatory, which one may be bedridden in room #1, and a hospice waiver for 6.

LPAs toured facility with Licensee Racquel Chou including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. A comfortable temperature is maintained at 78 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 11/14/2023. Emergency Disaster Plan was last posted on 07/18/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 07/18/2024. Fire drill was last conducted on 07/25/2024.

At 2:50pm, LPAs reviewed 6 residents records. At 3:30pm, LPAs reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility.

Continue on LIC 809-C...
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia ManaloTELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WELCOME HOME SENIOR RESIDENCE-ALAMO 3
FACILITY NUMBER: 079200631
VISIT DATE: 09/25/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/02/2024

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia ManaloTELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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