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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200933
Report Date: 09/26/2024
Date Signed: 09/26/2024 11:19:03 AM

Document Has Been Signed on 09/26/2024 11:19 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ISABELLA'S ARFFACILITY NUMBER:
079200933
ADMINISTRATOR/
DIRECTOR:		VASQUEZ, OSCAR EFACILITY TYPE:
735
ADDRESS:1758 HEATHERWOOD DRIVETELEPHONE:
(925) 267-4632
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 4CENSUS: 4DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Ana Garcia, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 9/26/2024 at 9:25am, Licensing Program Analysts (LPAs) L. Hall and P. Manalo conducted an unannounced annual required inspection. LPAs met with Ana Garcia, Caregiver, and explained the purpose of the visit. LPA spoke with back up Administrator, Maria Cumisky via telephone and explained the purpose of the visit. Facility has a fire clearance for 4 ambulatory clients. No clients were present during visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. All 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 110.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ISABELLA'S ARF
FACILITY NUMBER: 079200933
VISIT DATE: 09/26/2024
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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Emergency disaster plan updated 1/1/2024. Fire extinguisher was last services on 2/29/2024. Fire drill last conducted 9/2/2024. First aid kit was observed to be complete.

Four (4) staff records and all four (4) client records were reviewed, current and complete. LPAs reviewed P&I.

The following forms to be updated and submitted to CCLD by 10/3/2024.
  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources
  • Emergency Disaster Plan (last page only)


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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