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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201271
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:56:29 PM

Document Has Been Signed on 08/14/2024 01:56 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LAS TRAMPAS - SHEILA HOUSEFACILITY NUMBER:
079201271
ADMINISTRATOR/
DIRECTOR:		RUBIO, MARTHAFACILITY TYPE:
740
ADDRESS:9 SHEILA COURTTELEPHONE:
(925) 300-3839
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 4CENSUS: 4DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Martha Rubio, Director of Residential ServicesTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 08/14/2024 at 9:55 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met Direct Support Professional (DSP), Anthony Jones, and explained the purpose of the visit. Anthony phoned Director of Residential Services, Martha Rubio, who arrived around 10:10 AM. The facility’s fire clearance was approved for capacity of four (4) of which, two (2) may be non-ambulatory. DSP, Kerri Nordstrom, has an pending Administrator Certificate #6073133740.

LPA toured facility with Martha including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 4 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/08/2024. Emergency Disaster Plan was last posted on 08/01/2024. First aid kit was observed to be complete. Emergency disaster drill (fire and earthquake) was last conducted on 08/01/2024.

LIC809-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LAS TRAMPAS - SHEILA HOUSE
FACILITY NUMBER: 079201271
VISIT DATE: 08/14/2024
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LPA reviewed 4 residents records. LPA reviewed 8 staff records and 8 of 8 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/21/2024:

LIC 308 Designation of Administrative Responsibility - Reviewed
LIC 309 Administrative Organization - Reviewed
LIC 500 Personnel Report - Reviewed
LIC 610E Emergency Disaster Plan - Reviewed
Liability Insurance - Reviewed

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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