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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200902
Report Date: 04/25/2024
Date Signed: 04/25/2024 10:16:08 AM


Document Has Been Signed on 04/25/2024 10:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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: 3DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Administrator, Jacqueline BrownTIME COMPLETED:
10:20 AM
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On 04/25/2024 at 7:45 AM/PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Jacqueline Brown and explained the purpose of the visit. Clients away at day program. The facility’s fire clearance was approved for 6 Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 3 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105 degrees Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygienes were available for clients. There is a minimum of one week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/18/2023. Emergency Disaster plan (1 page) was last posted on 4/5/2023. LPA advised administrator to update plan and to include the 9 page LIC610E. First aid kit was observed to be complete. Fire drill and disaster drill was last conducted on 4/06/2024.

At 8:15AM, 3 of 3 clients records were reviewed. At 8:45am, 1 staff records were reviewed and 1 of 1 have current first aid training and associated to the facility. P&I and Surety Bond were reviewed.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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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