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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200883
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:42:02 PM

Document Has Been Signed on 09/01/2022 02:42 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:LA CALLE HAVENFACILITY NUMBER:
079200883
ADMINISTRATOR:LIPARDO, MELISSAFACILITY TYPE:
735
ADDRESS:1775 LA CALLETELEPHONE:
(925) 822-3610
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 5DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Eric Carlo Manalo
Care Giver		TIME COMPLETED:
02:55 PM
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On 09/01/2022 at 1:15 pm Licensing Program Analysts (LPAs) C. Fowler and P. Watson arrived unannounced to conduct infection control inspection LPAs met with care giver Eric Carlo Manalo and explained the purpose of the visit, administrator Bernadettemay Lee arrived approximately 1:45 pm.

During the Infection Control Inspection, LPAs toured facility including but not limited to common areas, kitchen, bedrooms, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Visitors policy is posted on the front door. Facility staff were observed wearing masks. Facility has a 30-day supply of PPE maintained at a central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit.

Continue on 809 C.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2022
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: LA CALLE HAVEN
FACILITY NUMBER: 079200883
VISIT DATE: 09/01/2022
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Continued from 809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by xx/xx/xxxx:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan
LIC 9020 Register of Facility Clients/Residents


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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