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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200787
Report Date: 10/01/2020
Date Signed: 10/02/2020 11:36:28 AM

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:DIANA'S CARE HOMEFACILITY NUMBER:
079200787
ADMINISTRATOR:REANO-AQUINO, GRACEFACILITY TYPE:
740
ADDRESS:27402 MANON AVETELEPHONE:
(510) 786-9982
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:35CENSUS: 32DATE:
10/01/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Grace AquinoTIME COMPLETED:
03:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a prelicensing tele visit and met with Administrator Grace Aquino. LPA explained to the Administrator that this visit is being conducted via Facetime in connection with the shelter in place order of the governor and telework directive of management. This is a change in ownership and facility has a fire clearance approved for 35 non ambulatory residents.

LPA inspected the facility inside and out including but not limited to backyard, kitchen, dining room/activity room, shower rooms and 4 resident rooms. LPA observed facility has sufficient lighting. Hallways and passageways inside and outside were observed free of obstructions. Food supplies were observed sufficient for seven (7) days of non-perishables and two (2) day of perishables. Hot water temperature in two shower rooms were tested and measured at 199 degrees Fahrenheit. Bathrooms/shower rooms were observed equipped with grab bars and non-skid mats. There were no bodies of water observed.

During inspection, LPA observed the following:
  • per facility sketch, Rooms 16 and 18 were designated as private rooms; however, LPA observed and Administrator confirmed that room 16 will be a shared room
  • there are only 2 designated shower rooms being used by the 32 residents
  • per facility sketch, one room that has an entrance from the outside of the building is designated as staff room; however, Administrator confirmed with LPA that it will be used as a resident shared room continuation on Lic 9099C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DIANA'S CARE HOME
FACILITY NUMBER: 079200787
VISIT DATE: 10/01/2020
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LPA will notify CAB analyst as soon as all the corrections have been completed.

Exit interview was conducted with Administrator and a copy of this report will be sent via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020
LIC809 (FAS) - (06/04)
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