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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200882
Report Date: 09/08/2022
Date Signed: 09/08/2022 04:52:37 PM


Document Has Been Signed on 09/08/2022 04:52 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:CHERISH CARE HOME INC.FACILITY NUMBER:
079200882
ADMINISTRATOR:OKEIGWE, OGEDIFACILITY TYPE:
740
ADDRESS:15 DICKSON LANETELEPHONE:
(925) 250-3044
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 5DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Kimarley Whyte, CaregiverTIME COMPLETED:
05:00 PM
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On 9/8/2022 at 4:05PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Kimarley Whyte, Caregiver, and explained the purpose of the visit.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, and kitchen. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 115.8 degrees Fahrenheit. Fire extinguisher last serviced on 1/5/2022. There is a minimum of 2-day perishables foods and 7-day non-perishables foods.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the mitigation plan on file. LPA observed food and paper supplies are sufficient.

Continued on LIC809C,
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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 3


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: CHERISH CARE HOME INC.
FACILITY NUMBER: 079200882
VISIT DATE: 09/08/2022
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Continued from LIC809.

LPA request the following documents to be submitted to CCLD by 9/15/2022.
  • LIC 9182 Infection Control Plan
  • LIC 610E Emergency Disaster Plan
  • A copy of Administrator Certificate
  • LIC308 Designation of Responsibility
  • LIC500 Personnel Record


No deficiencies cited during this visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3