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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201272
Report Date: 08/30/2024
Date Signed: 09/13/2024 10:12:25 AM

Document Has Been Signed on 09/13/2024 10:12 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:PERRY'S PLACE- EL MONTEFACILITY NUMBER:
079201272
ADMINISTRATOR/
DIRECTOR:
PERRY, LATISHAFACILITY TYPE:
735
ADDRESS:3962 EL MONTE RDTELEPHONE:
(415) 535-1472
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 4CENSUS: 0DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Latashia Perry, LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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Attempted Visit on 08/30/2024

On 0/09/23 at 05:20 PM, Licensing Program Analyst (LPA) L. Holmes arrived announced to conduct an annual Infection Control Inspection. LPA was greeted by Latashia Perry, Licensee

Facility has a COVID-19 mitigation plan, and Emergency Disaster Plan on file. Licensee has a staff roster and Emergency Disaster Plan posted. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, staff room, Four (4) bedrooms, bathrooms, kitchen, front and side pathways. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap and covered garbage cans. ADM to add paper towels to shared bathroom. There is a surplus of PPE stored centrally located inside the facility that is accessible to all care staff. The facility's temperature was 69 degrees (F) and waters tested at 108.4 F. Fire extinguisher observed full. First Aid complete.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610 Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate (s)

Exit interview conducted and a copy of this report provided to Latashia Perry, Licensee.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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