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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601390
Report Date: 06/06/2022
Date Signed: 06/06/2022 12:00:24 PM


Document Has Been Signed on 06/06/2022 12:00 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:AAA CARE HAVEN IIFACILITY NUMBER:
015601390
ADMINISTRATOR:SANTA ANA, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1890 GROVE WAYTELEPHONE:
(510) 331-7257
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:6CENSUS: 3DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Evelyn C Luciano, AdministratorTIME COMPLETED:
12:05 PM
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On 6/6/22 at 10:35 AM, Licensing Program Analysts (LPAs) K. Nguyen and C. Lin arrived unannounced to conduct Infection Control Inspection. LPAs met with Evelyn C Luciano, Administrator and explained the purpose of the visit..

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. Facility staffs 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 and maintains record of routine screening for residents and staff.

During record review, LPAs reviewed a sample of 2 staff records and observed 2 of 2 have health screening with TB test on file.



No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to Evelyn 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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