079201040-4-2-2021-15-AS-LIBO-BZPUJR-20210402153759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201040
Report Date: 04/02/2021
Date Signed: 04/02/2021 03:38:23 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:	CATHEDRAL CARE HOME		FACILITY NUMBER:	079201040
ADMINISTRATOR:	DATUIN, MARIVIC		FACILITY TYPE:	740
ADDRESS:	2707 CATHEDRAL CIRCLE		TELEPHONE:	(925) 222-8492
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 0	DATE:	04/02/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Marivic Datuin		TIME COMPLETED:	04:00 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 04/02/2021, Licensing Program Analyst (LPA) Leslie Ibo made a scheduled visit to this facility for the purpose of completing a Pre-licensing inspection. LPA met with Applicant Marivic Datuin. LPA observed no residents were present during today’s visit. At 10:30AM, LPA toured the entire premises indoors and outdoors. The facility has 7 bedrooms including, 1 staff bedroom, master bedroom and 1 guest room and 4 bathrooms including 1 staff bathroom, 2 residents’ bathrooms and 1 master bathroom, single story house per facility sketch. 4 bedrooms are designated for residents, 1 guest room for applicant’s minor son, 1 bedroom for staffs. LPA observed 1 fire extinguisher of which was located in the kitchen area. Smoke detectors and carbon monoxide detectors were observed operational. The facility received a fire clearance dated 03/09/2021 with an approval for a total capacity of 6 residents all approved for non-ambulatory. LPA observed a locked cabinet for centrally stored medications in the pantry adjacent to the kitchen island, per applicant they will use the pantry as their office since it is spacious enough for staff and residents records. Kitchen and dining room floors are clean and sanitary, food preparation area has an operating ventilation fan, there are no pesticides, poisons, or other toxins stored in any food storage or preparation area, cleaning supplies are kept separate from food supply. The facility has a supply of 7 days of non-perishable and 2 days of perishable foods in stock for six people. There are enough amounts of tableware, tables, dishes, and utensils. There are enough amounts of equipment for the storage, preparation of food. All equipment and dishes are clean and in good repair and there is at least 1 dining room convenient to the kitchen. Hot water temperature was tested at 110 degrees Fahrenheit. Refrigerator temperature was observed at 37.5 degrees Fahrenheit and freezer was observed at -0.4 degrees Fahrenheit. Continue LIC809C...

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

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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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: CATHEDRAL CARE HOME	FACILITY NUMBER: 079201040
	VISIT DATE: 04/02/2021

NARRATIVE

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7 Bedrooms were observed furnished with a bed, bedding, and night stand, a chair, and a closet space. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed. There is confidential storage for personnel and resident records. There are games, activity supplies, and reading materials available. There is an outdoor area, that appears comfortable and furnished for residents to entertain friends and relatives. LPA observed the first aid kit was complete with manual. All exit doors in the facility are equipped with auditory signals. Applicant has a pet living at the facility with completed vaccines. LPA verified there is an active telephone line in the facility, which is currently operating.

During today's visit, LPA reviewed LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements with applicant. LPA observed the facility had the necessary posters in place (Complaint poster, LTCO poster, Rights to Council, etc).

LPA conducted component III with Licensee/Administrator.

LPA recommends approval for the license pending, until the following items are completed:

· New facility sketch indicating “pantry” to be the facility office
· Facility sketch needed to be updated with only indication of number of bedroom, non-ambulatory and not Bed ridden
· 1 adult living at the home has pending fingerprint clearance,

Exit interview conducted with Marivic Datuin and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

LIC809 (FAS) - (06/04)

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