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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201034
Report Date: 05/25/2022
Date Signed: 05/25/2022 11:03:43 AM


Document Has Been Signed on 05/25/2022 11:03 AM - 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:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Joel AlipingTIME COMPLETED:
11:15 AM
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On 05/25/2022 at 10:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPA was greeted by Joel Aliping, Administrator (ADM) on entry and explained the purpose of the visit.

Facility has a COVID-19 mitigation plan on file. LPA requested a staff and resident roster once ADM admits residents. LPA advised ADM to create a screening station at the entry that contains a thermometer, hand sanitizer, masks, gloves, COVID-19 signage, and sign-in logs. LPA toured the facility including, but not limited to common areas, bathroom, bedrooms, kitchen, and backyard. LPA to send COVID-19 masks, cough etiquette, social distancing and hand washing signs for posting throughout. ADM to post 20 seconds hand washing signs to wash areas and add covered garbage cans to shared bedrooms. Advised ADM that there needs to be a 30-day supply of PPE centrally located at the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 116.3 degrees Fahrenheit (F) and The facility's temperature was 74 degrees (F). Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete. Fire extinguisher observed full but needs replacing, front and backyard needs landscaping completed, ADM to notify licensing five (5) days prior to receiving any clients.

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

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
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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