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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201004
Report Date: 12/06/2021
Date Signed: 12/06/2021 03:37:40 PM

Document Has Been Signed on 12/06/2021 03:37 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:BAKER'S HOMEFACILITY NUMBER:
079201004
ADMINISTRATOR:CRUZ, RONNEL DELAFACILITY TYPE:
735
ADDRESS:2214 BAKER CT.TELEPHONE:
(917) 750-5856
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Ronnel Dela CruzTIME COMPLETED:
03:55 PM
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On 12/6/2021, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with S2 . LPA called Administrator Ronnel Dela Cruz, Administrator arrived 2:30PM. LPA observed 2 clients during the visit. Facility has a completed mitigation plan. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. No bodies of water. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days.

Facility has enough 2-day perishable food and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE (mask). Facility has a mitigation plan and maintains record of routine screening for residents and staff.

LPA requested for an update regarding N95 FIT testing schedule for all staff.
No deficiency cited during the visit.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
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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