079201105-11-16-2021-15-AS-DPAO-C8TU7C-20211116141943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201105
Report Date: 11/16/2021
Date Signed: 11/16/2021 02:21:22 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:	CARING HEARTS ELDERLY HOME		FACILITY NUMBER:	079201105
ADMINISTRATOR:	SANTOS VAHID, ELVIRA		FACILITY TYPE:	740
ADDRESS:	3498 SWALLOW COURT		TELEPHONE:	(925) 948-5221
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	6	CENSUS: 0	DATE:	11/16/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Elvira Vahid, Applicant		TIME COMPLETED:	02:15 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 11/16/21 at 1PM, Licensing Program Analyst (LPA) Daisy Panlilio made a scheduled visit to this facility for the purpose of completing a pre-licensing inspection. LPA met with applicant and explained the purpose of the visit. LPA observed there were no residents present at the facility. 2 staff wearing face masks greeted LPA at the door. Facility has a mitigation plan in place dated 09/12/20 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with applicant as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks and no touch temperature probe. LPA toured the facility inside and outside. The facility is a 5 bedroom 2 bathroom single story house. All 5 bedrooms are designated for residents, one of which is a shared bedroom with an adjacent bathroom. There is one common bathroom located near the 2 private bedrooms. The fire extinguisher was located in the dining area adjacent to the kitchen. Smoke detectors are hardwired thru out the facility and carbon monoxide was observed operational. The facility received a fire clearance with an approval for 6 non-ambulatory residents per facility sketch. Centrally stored medications were observed locked in the kitchen cabinets. The garage contained locked cabinets for storing toxins, detergents, cleaning supplies, gardening supplies, and tools. Beds were made with appropriate linens and additional linens were observed to be on hand in a linen cabinet next to the hallway. Continued on next page, LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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: CARING HEARTS ELDERLY HOME	FACILITY NUMBER: 079201105
	VISIT DATE: 11/16/2021

NARRATIVE

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Furniture and lighting were observed to be safe and adequate. Each bedroom was furnished with a bed, bedding, a night stand, a chair, and sufficient closet space. Hot water temperature in the resident bathrooms tested at 109 degrees Fahrenheit. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed.

As this is a new facility, no residents were present during today’s visit. LPA verified there is an operating lan line telephone in the facility. During today's visit, LPA reviewed COVID-19 mitigation plan, LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements.

No deficiencies observed during the pre-licensing inspection. The facility is ready to be licensed. However, this report will be submitted to the central application unit (CAU) in Sacramento and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC809 (FAS) - (06/04)

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