019200657-7-24-2023-15-AS-LFII-CU2VXB-20230724164917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200657
Report Date: 07/24/2023
Date Signed: 07/24/2023 04:50:10 PM

Document Has Been Signed on 07/24/2023 04:50 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:	CMA CARE HOME		FACILITY NUMBER:	019200657
ADMINISTRATOR:	CRUZ, IMELDA M		FACILITY TYPE:	740
ADDRESS:	42909 HAMILTON WAY		TELEPHONE:	(510) 673-8038
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	6	CENSUS: 5	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Imelda Cruz, Licensee		TIME COMPLETED:	04:00 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 7/24/2023 starting at 12:50 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Imelda Cruz, Licensee and explained the purpose of the visit. The facility’s fire clearance was approved for all six (6) non-ambulatory residents, and approved for three (3) hospice waivers. Upon entry, LPA observed three (3) staff and one (1) residents present during inspection. Starting at 1:34 PM, LPA toured facility with licensee including but not limited to five (5) bedrooms, three (3) bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are private, and 1 shared room. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 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 106.7 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 detector were in operating condition during visit. Fire extinguisher was observed last serviced on 5/15/2023. 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: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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: CMA CARE HOME	FACILITY NUMBER: 019200657
	VISIT DATE: 07/24/2023

NARRATIVE

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Continued from Lic809

Starting At 1:57 PM, LPA reviewed 3 staff records. At 2:15 PM, LPA reviewed 5 of 6 residents' records. At 2:50 PM, LPA reviewed a sample of 5 of 6 residents' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/31/2023:

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

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: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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