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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200916
Report Date: 01/11/2024
Date Signed: 01/11/2024 10:47:34 AM

Document Has Been Signed on 01/11/2024 10:47 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:OUR HOMEFACILITY NUMBER:
079200916
ADMINISTRATOR:BANSIL, REYNANTEFACILITY TYPE:
735
ADDRESS:9692 TAREYTON AVENUETELEPHONE:
(510) 220-6712
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6CENSUS: 5DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Lead Care Staff, Eumelia MendozaTIME COMPLETED:
10:55 AM
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On 01/11/2024 at 7:45 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Lead Care Staff, Eumelia Mendoza and explained the purpose of the visit. Administrator is out of town and verbalized via phone that Eumelia can conduct and sign off on inspection. 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 4 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 68 degree 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 114.3 degree Fahrenheit. Refrigerator temperature measured at 32 degrees Fahrenheit and freezer measure at -13 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 2/07/2023. First aid kit was observed to be complete. Fire drill was last conducted on 11/07/2023.

At 8:25am, 4 of 5 clients records were reviewed. At 9am, 3 staff records were reviewed and 3 of 3 have current first aid training and are associated to the facility. 2 residents were at the facility at time of visit but unable to be interviewed.

Report continues on LIC809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OUR HOME
FACILITY NUMBER: 079200916
VISIT DATE: 01/11/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 02/01/2024:

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



No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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