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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441104
Report Date: 06/06/2022
Date Signed: 06/06/2022 01:22:29 PM


Document Has Been Signed on 06/06/2022 01:22 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:CASTRO VILLAGE CARE HOMEFACILITY NUMBER:
011441104
ADMINISTRATOR:TECSON, FIDELAFACILITY TYPE:
740
ADDRESS:3634 JAMISON WAYTELEPHONE:
(510) 398-8493
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:6CENSUS: 6DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Mirriam Papras, AdminstratorTIME COMPLETED:
01:30 PM
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On 6/6/22 at 12:20 PM, Licensing Program Analysts (LPAs) K. Nguyen and C. Lin arrived unannounced to conduct Infection Control Inspection. LPAs met with Caregiver, Ricardo Tria and explained the purpose of the visit. Administrator Mirriam Papras later arrived.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/13/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided Mirriam Administrator.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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