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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200977
Report Date: 05/24/2022
Date Signed: 05/24/2022 12:19:05 PM

Document Has Been Signed on 05/24/2022 12:19 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:WE CARE ELDERLY CAREFACILITY NUMBER:
079200977
ADMINISTRATOR:WHITE, BRITTANY DFACILITY TYPE:
740
ADDRESS:4155 BELL AVETELEPHONE:
(510) 375-4460
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 8CENSUS: 6DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Lurinza BeanTIME COMPLETED:
12:30 PM
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On 05/24/2022 at 11:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection, LPA was greeted by Lurinza Bean, Licensee. Upon entry, LPA explained the purpose of the visit, advised Licensee that all temperatures needed to be checked with a thermometer prior to entry.

Facility has a COVID-19 mitigation plan on file. LPA requested a staff and resident roster be sent to CCLD by 05/27/2022. LPA observed a screening station at the entry that contained hand sanitizer, masks, gloves, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathroom, bedrooms, kitchen, garage and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs; 20 seconds need to posted throughout at hand washing stations. Create an isolation cart with PPE in the event there is an outbreak. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and covered garbage cans. Hot water temperature in the shared residents' bathroom was measured at 118.4 degrees Fahrenheit (F) and facility temperature was 71 degrees (F). Fire extinguisher was observed full and serviced 06/20/2021. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD: 05/31/2022:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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