<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201250
Report Date: 04/18/2023
Date Signed: 04/18/2023 12:43:11 PM

Document Has Been Signed on 04/18/2023 12:43 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:MA'AT HOME SUPPORT SERVICESFACILITY NUMBER:
079201250
ADMINISTRATOR:FONTENOT, ROBINFACILITY TYPE:
735
ADDRESS:5301 POTRERO AVETELEPHONE:
(510) 932-5910
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 3CENSUS: 0DATE:
04/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Robin Fontenot, Administrator TIME COMPLETED:
01:00 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 04/18/23 at 10:40 AM, Licensing Program Analyst (LPA) L. Holmes arrived announced to conduct a Pre-licensing Inspection. Upon arrival, LPA was greeted by Robin Fontenot, Administrator (ADM) and LaDonna Ford, Program Manager. The facility's fire clearance was approved for three (3) Clients, all ambulatory.

LPA toured facility with Administrator and including but not limited to three (3) bedrooms, two (2) bedrooms, kitchen, living room, dinning room, laundry room, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with non-skid mats. Linens and hygiene supplies were observed inside a closet and a locked closet for medication. There is sufficient lighting throughout facility and hallways. Room temperature was comfortable and water temperature was maintained at 105.3 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide are combined and operational. Fire extinguisher was observed full. There were at least 2-days of non-perishables and 7-days of perishable foods. Landscaping and gardening tools to be place in locked area after backyard grass is trimmed.

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.

Exit interview conducted and a copy of this report provided to Robin Fontenot, Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1