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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201021
Report Date: 12/28/2020
Date Signed: 12/28/2020 03:44:16 PM

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:M&E CAREFACILITY NUMBER:
079201021
ADMINISTRATOR:SANTOS, MARIA DELOSFACILITY TYPE:
740
ADDRESS:461 LIMERICK ROADTELEPHONE:
(510) 669-5015
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY:6CENSUS: 4DATE:
12/28/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria DeLos Santos, AdministratorTIME COMPLETED:
03:30 PM
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On 12/28/2020 at 1:00PM, Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit Pre-Licensing inspection via FaceTime due to shelter in place directed by the Governor. LPA spoke with Administrator, Maria DeLos Santos. The facility's fire clearance was approved for 4 non-ambulatory and 2 bedridden residents.

During the Tele-Inspection, LPA toured facility with Administrator including but not limited to bedrooms, bathroom, common areas, kitchen, garage and outdoor area. Resident's bedrooms are fully furnished with bed, dresser, night stand, and chair. Resident's bathroom was equipped with grab bars and showers have non-skid mat. LPA observed lighting in all rooms. LPA observed facility has a 7-day non-perishable and 2-day perishable food supplies. Medications were locked in a kitchen cabinet. Smoke detectors are interconnected. Carbon Monoxide detector was observed. First aid kit is complete. Administrator had check the hot water temperature this morning which was 105 degrees F. LPA advised Administrator that hot water temperature should be maintained between 105 degrees F and 120 degrees F. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was observed to be full. Emergency disaster plan was completed on 6/12/2020.

At 1:45PM, LPA observed side gate was locked. Administrator removed the lock during inspection.

LPA conducted Component III with Administrator during Tele-visit. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.

This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and a copy of this report will be emailed.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
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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