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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440152
Report Date: 02/27/2023
Date Signed: 02/27/2023 07:10:22 PM


Document Has Been Signed on 02/27/2023 07:10 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:GALICIA'S TULIP CARE HOMEFACILITY NUMBER:
011440152
ADMINISTRATOR:GALICIA, CONSUELOFACILITY TYPE:
740
ADDRESS:1771 TULIP AVE.TELEPHONE:
(510) 782-6355
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 1DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:05 PM
MET WITH:Staff, Leonisa Tica and Jaime TicaTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Leonisa Tica and Jaime Tica, and informed the purpose of visit. LPA called and spoke with Consuelo 'Connie' Galicia, licensee-administrator. Connie Galicia can not come to the facility, and authorized Leonisa Tica to be with LPA during inspection. and sign this report.

Facility has an approved LIC808 Mitigation Plan. Licensee submitted the LIC9282 Infection Control Plan which LPA received on July 18, 2022.

LPA toured the facility inside out. LPA inspected the living room, dining area, family room, kitchen, hallways, residents bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Facility keeps record of proof of vaccination of residents and staff. COVID-19 signages were observed throughout the facility.

Fire extinguisher checked, and observed fully charge with tag showed serviced April 8, 2022.

Licensee-administrator stated she is planning to close the facility. LPA advised if the decision is final, to submit a signed letter along with a copy of the 60-day notification to the resident and/or resident's responsible person.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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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