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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200937
Report Date: 09/21/2022
Date Signed: 09/21/2022 05:02:42 PM


Document Has Been Signed on 09/21/2022 05:02 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:AGING IN THE BAYFACILITY NUMBER:
079200937
ADMINISTRATOR:CHARMAINE MENDAROSFACILITY TYPE:
740
ADDRESS:4617 HIDDEN GLEN DRTELEPHONE:
(925) 206-4770
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 2DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:42 PM
MET WITH:Charmaine Mendaros, AdministratorTIME COMPLETED:
05:30 PM
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On 9/21/22 at 3:42 PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct infection control inspection. LPA met with administrator and explained the purpose of the visit. LPA observed 2 staff wearing face masks and eyeglasses. LPA observed the 2 residents resting inside their bedrooms.

LPA toured the facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs maintained at a central location and easily accessible for staff. Comfortable temperature is maintained at 76 deg F. Facility has a mitigation plan in place and maintains records of routine screening for residents and staff. The infection control leader is the administrator.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/22/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan including infection control plans
· Evidence of Liability insurance

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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