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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200940
Report Date: 12/27/2021
Date Signed: 12/27/2021 05:17:31 PM


Document Has Been Signed on 12/27/2021 05:17 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:NEW ALAMO RESIDENCE HOMEFACILITY NUMBER:
079200940
ADMINISTRATOR:SAXENA, MEERANFACILITY TYPE:
740
ADDRESS:836 STONE VALLEY RDTELEPHONE:
(925) 743-1565
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: 6DATE:
12/27/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Meeran Saxena, AdministratorTIME COMPLETED:
05:25 PM
NARRATIVE
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On 12/27/2021 starting at 3:30 PM, Licensing Program Analyst (LPA) L. Francisco conducted a Health and Safety Inspection as a result of the Deparment receiving a Priority 1 complaint (#15-AS-20211222084738). LPA met with Administrator, Meeran Saxena.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. There is a minimum of 2-day perishable and one week non-perishable food supply. LPA observed smoke detectors and carbon monoxide throughout facility. Fire extinguishers were observed to be fully charged.

LPA reviewed LIC 500 and observed facility has sufficient staffing to meet resident's needs.

-At 3:25 PM during record review, LPA observed S1 is fingerprint cleared. However, is not associated to the facility.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2021
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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Document Has Been Signed on 12/27/2021 05:17 PM - It Cannot Be Edited

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: NEW ALAMO RESIDENCE HOME
FACILITY NUMBER: 079200940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
12/29/2021
Section Cited

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87355(c)(1)CRIMINAL RECORD CLEARANCE
(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another,..providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02).
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This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. LPA observed S1 is fingerprint cleared. However, not associated to the facility which poses a potential health and safety risk to resdients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2021
LIC809 (FAS) - (06/04)
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