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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200902
Report Date: 03/16/2023
Date Signed: 03/16/2023 03:01:37 PM


Document Has Been Signed on 03/16/2023 03:01 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:NINA'S CARE HOMEFACILITY NUMBER:
079200902
ADMINISTRATOR:BROWN, JACQUELINEFACILITY TYPE:
740
ADDRESS:4272 GLAZIER CTTELEPHONE:
(510) 205-8491
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 1DATE:
03/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Jacqueline Brown, AdministratorTIME COMPLETED:
03:15 PM
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On 3/16/2023 at 12:55 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Jaqueline Brown and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Ambulatory only.

LPA toured facility with Jacqueline including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are occupied by the residents and 2 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and two day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 9/15/2022. First aid kit was observed to be complete. Emergency disaster drill was last conducted 3/09/2023.

Report continues on 809C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NINA'S CARE HOME
FACILITY NUMBER: 079200902
VISIT DATE: 03/16/2023
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At 1:30 pm, LPA reviewed 1 residents records. At 1:40 pm, LPA reviewed 1 staff records, they have current first aid training and associated to the facility. At 1:15 pm, LPA reviewed a sample of resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/06/2023:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC809 (FAS) - (06/04)
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