<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200977
Report Date: 05/23/2023
Date Signed: 05/23/2023 07:03:35 PM

Document Has Been Signed on 05/23/2023 07:03 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: 5DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
06:15 PM
MET WITH:Brittany White, AdministratorTIME COMPLETED:
07:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/23/23 at 02:15 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced for an annual inspection and complaint investigation. Upon arrival, LPA met with Tenilius Hampton, Care Staff and explained the reason for the visit. Licensee Lurinza Bean and Administrator Brittany White (ADM) were both telephoned by Care Staff. ADM due to arrive in about 45 minutes. One (1) resident was present and two (2) staff. ADM arrived at 03:40 PM and had to departed around 5:00 PM. ADM certificate (6060553740) expires 09/20/23.

Upon arrival LPA observed one (1) staff monitoring the facility and attending to the resident that was watching television in his/her room. LPA and Care Staff toured the facility including, but not limited to bathrooms, kitchen, common areas, laundry area, dining area, front yard and backyard. The facility consists of 4 (four) bedrooms. All outdoor and indoor passageways are free of obstruction. There were no bodies of water. A comfortable temperature was maintained at 76 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared residents' bathroom was measured at 109.9 degrees (F). All toilets, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing signs, paper towels, and soap observed at all hand washing stations. Linen and hygiene products available for all residents. PPE, sanitizer, and paper goods remain sufficient.

...continued on LIC809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 17
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: WE CARE ELDERLY CARE
FACILITY NUMBER: 079200977
VISIT DATE: 05/23/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
...continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and new tag to be replaced on 05/30/23. Emergency Disaster Plan is updated.

Four (4) staff records were reviewed, all staff have criminal record clearances, and files are incomplete. Five (5) residents records were reviewed and are complete.

The following forms are to be updated and submitted to CCLD by 05/26/23:
-Resident Roster
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Reviewed)


The following items to be corrected and submit photo proof by 05/30/23:
-Create emergency binder, and organize staff files with dividers/tabs
-Conduct quarter emergency disaster drill.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 17