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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201034
Report Date: 03/26/2021
Date Signed: 03/26/2021 04:37:38 PM

Document Has Been Signed on 03/26/2021 04:37 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:AMIABLE CARE HOMEFACILITY NUMBER:
079201034
ADMINISTRATOR:ALIPING, JOELFACILITY TYPE:
740
ADDRESS:5180 VALLEY VIEW ROADTELEPHONE:
(510) 598-5272
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 6CENSUS: 0DATE:
03/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Joel Aliping, Applicant/AdministratorTIME COMPLETED:
05:00 PM
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On 03/26/21 at 4:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a tele-visit with applicant/administrator to complete the pre-licensing inspection. Due to COVID-19 shelter in place, applicant/administrator was not physically available to sign this report.

During the tele-visit, a component III presentation was conducted by LPA with applicant/administrator. LPA went over the Title 22 regulations/sections and discussed most common deficiencies at RCFE facilities and how to mitigate their occurrence. Applicant/administrator agreed to use the CCL website to familiarize himself with provider information notices (PINs), links and get updated information on COVID-19 protocols.

Applicant was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification can be done by phone, fax or mail.

Exit interview conducted and a copy of this report provided to applicant/administrator.
SUPERVISORS NAME: Rajind Basi
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2021
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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