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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200896
Report Date: 11/03/2021
Date Signed: 11/03/2021 01:06:51 PM

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:CASA SAN LORENZOFACILITY NUMBER:
019200896
ADMINISTRATOR:HOSAIN, MARIA LUISAFACILITY TYPE:
740
ADDRESS:171 VIA LINARESTELEPHONE:
(510) 329-9300
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:6CENSUS: 5DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Maria Hosain, AdministratorTIME COMPLETED:
01:15 PM
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On 11/03/2021 starting at 11:09 AM, Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with staff Eloisa Guevara and explained the purpose of the visit. (Administrator, Maria Hosain later arrived at 11:50am.)

Upon entry, LPA’s temperature was checked by the staff. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, common areas, and outdoor areas. There is one central entry point for universal screening for staff, residents, and visitors. Thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE.

Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility maintained supply of PPEs at central location and easily accessible for staff. Facility has Mitigation Plan and Emergency Disaster Plan on file.

No deficiency cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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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