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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201250
Report Date: 04/26/2023
Date Signed: 04/26/2023 09:49:44 AM

Document Has Been Signed on 04/26/2023 09:49 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: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:
04/26/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Robin Fontenot, AdministratorTIME COMPLETED:
10:00 AM
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On 04/26/23 at 09:00 AM, Licensing Program Analysts (LPA) L. Holmes arrived announced to conduct a Component II from a Pre-licensing inspection on 04/18/23. LPA completed a Component III presentation with Robin Fontenot, Administrator (ADM) and LaDonna Ford, Program Manager.

LPA discussed the COVID-19 infection control requirements, the importance of attending the informational calls, understanding the updated guidelines and printing the provider information notices (PINS) for clients, authorized representatives and staff so that the facility maintains awareness and updates for compliancy with the Title 22 regulations.

-Component III completed.

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: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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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