015601315-8-4-2023-15-AS-LFII-CUDUUL-20230804155342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601315
Report Date: 08/04/2023
Date Signed: 08/04/2023 03:53:57 PM

Document Has Been Signed on 08/04/2023 03:53 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:	ISHERWOOD CARE III		FACILITY NUMBER:	015601315
ADMINISTRATOR:	CAYABYAB, LAURO & ZORAIDA		FACILITY TYPE:	740
ADDRESS:	1445 SKELTON AVENUE		TELEPHONE:	(510) 894-4571
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	6	CENSUS: 4	DATE:	08/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Lauro, Cayabyab- Administrator (ADM)		TIME COMPLETED:	04:10 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 8/4/2023, starting at 12:50 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Lauro, Cayabyab- Administrator (ADM) and explained the purpose of the visit. Administrators certificate (6009286740) is valid and expires on 11/28/2023. The facility’s fire clearance was approved for six (6) residents, which all may be non-ambulatory; hospice waiver approved for two (2) residents only. Upon entry, LPA observed three (3) staff and four (4) resident present during inspection. Starting at 1:10 PM, LPA toured facility with ADM including but not limited to five (5) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are private, one room is shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 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 114.0 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply 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 8/25/2021. 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: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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: ISHERWOOD CARE III	FACILITY NUMBER: 015601315
	VISIT DATE: 08/04/2023

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Continued from Lic809

Starting At 1:48PM, LPA reviewed 3 of 3 staff records. At 1:55PM, LPA reviewed 4 of 4 residents' record which are current. At 2:50PM, LPA reviewed 4 of 4 residents' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 8/11/2023:

· 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 ADM, 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: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC809 (FAS) - (06/04)

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