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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200739
Report Date: 09/14/2021
Date Signed: 09/14/2021 04:11:09 PM

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:DESIRED PEACE HOME CAREFACILITY NUMBER:
079200739
ADMINISTRATOR:LAM, PAUL, KFACILITY TYPE:
740
ADDRESS:2181 WAYNE DRTELEPHONE:
(510) 759-8889
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
09/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Paul LamTIME COMPLETED:
04:40 PM
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LPA provided technical assistance on the following topics :


Document daily COVID-19 symptom checks, and any change in condition for staff and residents.

Staff training on infection prevention, symptoms, transmission and PPE use. Type B violation was cited.

]Adequate 30-day supply of PPE (e.g., face masks, respirators, gowns, gloves, and eye protection such as face shield or goggles).

Signs to promote hand washing, cough/sneeze etiquette, and physical distancing.

Signs to encourage residents to report acute respiratory illness to staff.

Using CCLD website to check latest PIN.

How to set up a covid19 station for covid19 positive facility.

LPA discussed with Administrator the importance of the topics above.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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