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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601319
Report Date: 06/26/2024
Date Signed: 06/26/2024 12:18:54 PM


Document Has Been Signed on 06/26/2024 12:18 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:A NEW HAVEN CARE HOME - ADAMSFACILITY NUMBER:
015601319
ADMINISTRATOR:SOLETA, ARNOLD B.FACILITY TYPE:
740
ADDRESS:814 ADAMS AVENUETELEPHONE:
(925) 292-8244
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:6CENSUS: 4DATE:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lizbeth Cruz, CaregiverTIME COMPLETED:
12:35 PM
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On 6/26/2024 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Martin Riva and Lizbeth Cruz. The facility’s fire clearance was approved for 5 non-ambulatory residents and 1 bedridden resident.

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 2/2/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 105.3 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 6/4/2024.

LPA reviewed 4 residents and 3 staff files starting at 10:15AM. LPA reviewed a sample of resident's medications starting at 11:11AM. LPA interviewed 2 residents and 2 staff at 11:30AM.

No deficiencies are being cited on this date.

Exit interview conducted with Lizbeth Cruz. 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: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
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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