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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200711
Report Date: 10/03/2024
Date Signed: 10/17/2024 01:48:21 PM


Document Has Been Signed on 10/17/2024 01:48 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:SCOTT RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200711
ADMINISTRATOR:VIZCARRA, MARIA JANICEFACILITY TYPE:
740
ADDRESS:1127 SCOTT PLACETELEPHONE:
(510) 397-1614
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: 6DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Maria Jance Vizcarra, Administrator TIME COMPLETED:
02:15 PM
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On 10/3/24 LPA arrived at the facility to conduct an unannounced required 1 year annual visit. LPA observed that there was no one at the facility. LPA spoke to administrator (ADM), Janice Vizcarra and explained the purpose of the visit. ADM stated the facility do not have any clients due being in day program and out in the community. LPA will attempt another visit at a later time.

Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection continuation. LPA met with Administrator Maria Janice Vizcarra. The facility is a Residential Care Facility for the Elderly (RCFE) vendorized by the Regional Center of the East Bay (RCEB) as Level 4F. Facility has an approved fire clearance for 2 non ambulatory and 4 ambulatory residents. LPA observed no client at the facility during inspection.

LPA with Administrator inspected the facility inside and out including but not limited to client rooms, staff rooms, bathrooms and living room, kitchen, garage, and backyard. Facility has sufficient 2 days supply of perishable and 7 days supply of non perishable foods. There are supply of hygiene products, towels, sheets and warm blankets were observed. Two fire extinguishers were observed full and inspected on 5/13/2024. First aid kit was observed complete. P&I money and log were verified and observed accurate and updated. Hot water measured at 100.9 degrees Fahrenheit. Carbon monoxide and smoke detectors were tested and observed functional. Emergency Disaster Plan was last posted on 02/24/2024. Fire drill, Earthquake, and shelter in place was last conducted on 07/19/2024. Surety bond insured 5/6/22 to 5/5/25.

LPA reviewed 5 clients’ records and 3 staff records, and all were complete. Client’s medications/ PNI were reviewed.

No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
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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