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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201151
Report Date: 04/18/2022
Date Signed: 04/18/2022 03:58:27 PM

Document Has Been Signed on 04/18/2022 03:58 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:HERITAGE HOME ARFFACILITY NUMBER:
079201151
ADMINISTRATOR:BONIFACIO, ALFREDO JRFACILITY TYPE:
735
ADDRESS:14 RED BARN CT.TELEPHONE:
(925) 679-0845
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 5DATE:
04/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:ALFREDO BONIFACIO JR. TIME COMPLETED:
02:30 PM
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On 4/18/2022 Licensing Program Analyst (LPA) L. Ibo unannounced conducted pre-licensing inspection. LPA met with Applicant Alfredo Bonifacio Jr. Facility has census of 5. LPA observed 4 clients were present during today’s visit with 1 client out and at a day program.

At 10:36 AM, LPA toured the entire premises indoors and outdoors. The facility has 7 bedrooms including master bedroom, 4 bathrooms including master bathroom, two story house per facility sketch. 6 bedrooms are designated for clients. LPA observed 2 fire extinguisher which was in the kitchen and second floor of the home. Smoke detectors and carbon monoxide detectors were observed operational. The facility received a fire clearance dated 03/25/2022 with an approval for capacity of 6 ambulatory clients only.

LPA observed a locked cabinet for centrally stored medications at the kitchen area. 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 have at least 2 days nonperishable food. 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 114.4 degrees Fahrenheit. Refrigerator temperature was observed at 37 degrees Fahrenheit and freezer was observed at 0 degrees Fahrenheit.

Continue LIC809C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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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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: HERITAGE HOME ARF
FACILITY NUMBER: 079201151
VISIT DATE: 04/18/2022
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6 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. 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. LPAs observed the facility had the necessary posters in place (Complaint poster, LTCO poster, Rights to Council, etc). COVID-19 posters were also displayed in the main entrance, common areas and the bathrooms.

Comp III was discussed with applicant.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) 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 with Applicant Alfredo Bonifacio Jr. and a copy of report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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