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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200849
Report Date: 07/07/2022
Date Signed: 07/07/2022 01:30:30 PM

Document Has Been Signed on 07/07/2022 01:30 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:ALICIAS HEAVENLY CARE HOMEFACILITY NUMBER:
079200849
ADMINISTRATOR:GONZALEZ, MICHELLEFACILITY TYPE:
735
ADDRESS:2212 TRINITY DRTELEPHONE:
(925) 390-6883
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 5DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Michelle Gonzalez, Administrator TIME COMPLETED:
01:45 PM
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On 7/7/2022 at 12:00 PM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Licensee Frederick Virden, at about 12:20 PM Administrator Michelle Gonzalez arrived at the facility. LPA observed 0 clients at the home, Administrator stated that all clients are out and went for a walk at the park with staff Alicia Virden.

LPA inspected the facility inside and outside. Pool was properly secured and locked. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. LPA observed COVID-19 posters posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing & infection control. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Facility has enough supplies of PPEs, paper supplies and hygiene supplies.


...Continue to LIC809C....
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
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 2
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: ALICIAS HEAVENLY CARE HOME
FACILITY NUMBER: 079200849
VISIT DATE: 07/07/2022
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Medications are centrally stored in a locked area that is inaccessible to clients and refilled least every 30 days. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 75 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Refrigerator temperature was observed at 40 degrees Fahrenheit and freezer was observed to be at zero degrees Fahrenheit. Fire extinguisher last service date was March 2022. Smoke and Carbon monoxide detectors were operational.

No deficiency cited during the visit.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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