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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600740
Report Date: 09/12/2023
Date Signed: 09/12/2023 11:26:31 AM


Document Has Been Signed on 09/12/2023 11:26 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:A NEW HAVEN CARE HOMEFACILITY NUMBER:
015600740
ADMINISTRATOR:ROBERT ABELLAFACILITY TYPE:
740
ADDRESS:949 DOLORES STREETTELEPHONE:
(925) 784-3842
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 3DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Robert Abella, AdministratorTIME COMPLETED:
11:40 AM
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On 9/12/2023 at 8:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Leah Van Alstin and explained the purpose of the visit. Administrator, Robert Abella arrived 30 minutes later. The facility’s fire clearance was approved for 6 non-ambulatory residents of which 2 residents maybe under hospice care.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 2/9/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 105 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. Last fire drill was conducted on 7/10/2023.

LPA reviewed 3 resident and 2 staff files starting at 9:30AM. LPA reviewed a sample of resident's medications starting at 10:00AM. LPA interviewed 2 residents and 1 staff at 10:50AM.

No deficiencies being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
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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