015601017-8-7-2023-15-AS-LFII-CUGU72-20230807151914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601017
Report Date: 08/07/2023
Date Signed: 08/07/2023 03:19:23 PM

Document Has Been Signed on 08/07/2023 03:19 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	MISSION VILLA RESIDENTIAL CARE HOME		FACILITY NUMBER:	015601017
ADMINISTRATOR:	RUBIO, MARISSA		FACILITY TYPE:	740
ADDRESS:	42423 PASEO PADRE PARKWAY		TELEPHONE:	(510) 656-0168
CITY:	FREMONT	STATE: CA	ZIP CODE:	94539
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:43 PM
MET WITH:	Marissa Rubio, Licensee		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 8/7/2023, starting at 12:43 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Marissa Rubio, Licensee and explained the purpose of the visit. Administrators certificate (6008596740) is valid and expires on 11/25/2023. The facility’s fire clearance was approved for all six (6) non- ambulatory residents. Upon entry, LPA observed four (4) staff and two (2) residents present during inspection. Starting at 1:03 PM, LPA toured facility with care staff, including but not limited to five (5) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 2 bedrooms are private, 2 room is shared and one staff room. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 78 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ common area bathroom was measured at 112.5 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Sharps and toxins were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 7/27/2023. First aid kit was observed to be complete. Continue on Lic809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MISSION VILLA RESIDENTIAL CARE HOME	FACILITY NUMBER: 015601017
	VISIT DATE: 08/07/2023

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Continued from Lic809

Starting At 1:21 PM, LPA reviewed 4 of 4 staff records. At 1:41 PM, LPA reviewed 6 of 6 residents' record which are current. At 2:30 PM, LPA reviewed a sample of 6 of 6 residents' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/14/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 Pages)
· Liability Insurance

No deficiencies cited during visit.

Exit interview conducted with Licensee, and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

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